| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | Windows, screens and doors shall be in good repair. There were two window screens located in the back porch/laundry room area with holes at the time of the inspection. A window on the right side of the room had a screen with several small holes, and a window on the left side had a screen with one large hole. | Screens, windows and doors shall be in good repair. | Maintenance did not realize the screen had holes. The screens were replaced. Picture has been sent. |
02/20/2026
| Implemented |
| 6400.46(a) | Program specialists and direct service workers shall be trained before working with individuals in general fire safety. Staff #1 was hired on 3/24/2025 and began working with individuals on 3/31/2025 but did not receive training in fire safety until 4/09/2025. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | This was a training schedule error; Fire safety training is usually done on day one of training before in home orientation. Ongoing, the trainer will make the first day of training for fire safety and other essential training. |
02/20/2026
| Implemented |
| 6400.46(c) | Program specialists and direct service workers shall be trained before working with individuals in first aid techniques. Staff #1 was hired on 3/24/2025 and began working with individuals on 3/31/2025 but did not receive training in first aid during orientation training. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | This was a training schedule error; Fire safety and first aid training is usually done on day one of training before in home orientation. Ongoing, the trainer will make the first day of training for fire safety and all other essential training. |
02/20/2026
| Implemented |
| 6400.46(d) | Program specialists and direct service workers shall be trained within six months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff #1 was hired and began employment on 3/24/2025 but did not receive training by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation until 10/10/2025, more than six months after the date of initial employment. Per the current Chapter 6400 Regulatory Compliance Guide (RCG), there are no grace periods for staff training. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The staff did her first aid on 10/10/23, and her renewal was done on 10/10/25. Both certificates were in her file. I sent copies of the certificates to the inspector. |
02/20/2026
| Implemented |
| 6400.213(1)(i) | 213(1)(ii) Each individual's record shall include the following personal information: religion. The record for Individual #1 does not include the individual's religion or religious affiliation. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The program specialist forgot to review the face sheet after the individual admission. The program specialist got her religion affiliation from the individual's mother and corrected the error. |
02/20/2026
| Implemented |