| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | At the time of inspection, the rear porch light was non-functional via its associated switch, resulting in unsafe lighting conditions in the rear of the home. Provider maintenance staff found that the bulb was burnt out and replaced it prior to the conclusion of the on-site inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Light was fixed while the inspector was present |
09/30/2025
| Implemented |
| 6400.82(f) | At the time of inspection, there was no toilet paper in the basement bathroom. In addition, there was no soap in the bathroom off the home's first-floor hallway. These items were located within the home and placed within each bathroom, respectively, prior to the conclusion of the on-site inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Expectations for supply needs will be reviewed with staff. |
09/30/2025
| Implemented |
| 6400.141(c)(3) | Individual #1 was admitted to the provider's program effective 10/30/2024. Per a Physical Examination Form located in the Individual Record, this individual's pre-admission physical examination took place on 09/24/2024. The Physical Examination Form contained a section to list the individual's immunizations, which was left blank by the physician completing the form. A separate document titled "Vaccine Administration and Refusal Record" was present in the Individual Record; however, this form was not dated. As this immunization form was not dated the same date as, attached to, or referenced by the Physical Examination Form, it cannot be established to have been a part of the physical examination. Immunizations for individuals aged 18 or older shall be included in the physical examination. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | HR will be giving physical packets out during interviews and requiring completion prior to the Orientation start date. |
09/01/2025
| Implemented |
| 6400.141(c)(14) | Individual #1 was admitted to the provider's program effective 10/30/2024. The Physical Examination Form, dated 09/24/2024, contained a section designated for "Information Pertinent to Diagnosis and Treatment in case of Emergency"; however, this section was left blank by the doctor completing the form. This information was not found elsewhere within the physical examination. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | New case manager is reviewing all files to ensure that the full physical is scanned at the time of admission and updates. |
10/31/2025
| Implemented |
| 6400.151(a) | Staff #1's two most recent physical examinations occurred on 12/02/2023 and 01/29/2025, more than two years apart.
Staff #2 was hired by the provider effective 03/03/2025. Per the staff record, Staff #2's initial staff physical examination occurred on 03/03/2025---on the staff's date of hire. This staff physical examination did not occur within 12 months prior to the staff's hire date as required. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff will be retrainined on the importance of completing physicals when assigned. |
08/31/2025
| Implemented |
| 6400.151(c)(2) | Staff #2 was hired by the provider effective 03/03/2025. Per the initial staff physical examination, dated 03/03/2025, a Mantoux test was placed on 03/03/2025 and read negative on 03/05/2025. This physical did not contain tuberculin testing with a negative result prior to the staff's date of hire as required. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | HR will be giving physical forms out during interviews and expecting completion prior to start of orientation. |
09/01/2025
| Implemented |
| 6400.32(r)(1) | The doorknob on Individual #1's bedroom door was not equipped with a locking mechanism. This individual's right to privacy in the bedroom was not maintained. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Door knob was corrected by the next week. |
09/01/2025
| Implemented |
| 6400.181(f) | Individual #1 was admitted to the provider's program effective 10/30/2024. Per documentation found within the Individual Record, this individual's Initial Individual Assessment was completed 11/30/2024; however, there was no evidence that this assessment was provided to the members of the individual's Individual Plan Team prior to the Individual Plan meeting on 05/09/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Newly hired Case Manager was given education in completion and time frames for Annual assessments |
10/31/2025
| Implemented |