| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 3/18/2026 at 1:46PM, the hot water temperature measured 122.3°F at the sink in the kitchen of the home. [Repeat Violation, 5/21/2025] | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The violation occurred because the hot water temperature exceeded the allowable limit and was not identified and corrected during routine environmental checks. On 3/19/2026, the landlord and maintenance staff was notified, and the hot water temperature at the kitchen sink was adjusted to within the acceptable range. The corrected water temperature was rechecked and confirmed by management. |
03/30/2026
| Implemented |
| 6400.67(a) | On 3/18/2026 at 1:52PM, the wooden bottom of the vanity was detached from the base and fell off when the cabinet doors were opened in the bathroom on the first floor of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | The violation occurred because the damaged vanity was not identified and corrected during routine environmental checks. On 3/25/2026, the detached vanity base was repaired so that the bathroom surface is now in good repair. The program manager confirmed the correction during a site inspection. See the attached pictures. |
03/30/2026
| Implemented |
| 6400.68(b) | On 3/18/2026 at 1:54PM, the hot water temperature measured 125.4°F at the bathtub on the first floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The violation occurred because the bathtub hot water temperature exceeded the allowable maximum and was not corrected prior to the inspection. On 3/19/2026, the water heater was adjusted so that the bathtub water temperature no longer exceeds 120°F. The corrected temperature was rechecked and confirmed by management. |
03/30/2026
| Implemented |
| 6400.72(b) | On 3/18/2026 at 2:03PM, there was a three-inch by four-inch tear in the bottom right corner and several other small tears throughout the screen in the only window in Individual #1's bedroom. At 2:40PM, there was a three-inch by one-inch tear on the right side and a two-inch tear on the left side in the screen in the window on the right side of the dining room of the home. | Screens, windows and doors shall be in good repair. | The violation occurred because damaged window screens were not identified and repaired during routine site checks. On 3/19/2026, the torn screens in Individual #1's bedroom and the dining room were repaired so that all cited screens are now intact and in good repair. The program manager verified completion of the repairs. See pictures attached. |
03/30/2026
| Implemented |
| 6400.101 | On 3/18/2026 1:58PM, the metal door jamb on the right side was loose, causing the storm door to stick and making it very difficult to open the door posing an obstructed egress. [Repeat Violation, 5/21/2025] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The violation occurred because the damaged door jamb was not corrected timely and the storm door became difficult to open, creating an obstructed means of egress. On 3/25/2026, the loose metal door jamb was repaired so the storm door opens freely and the exit path is unobstructed. The program manager verified that the door functions properly. See pictures attached. |
03/30/2026
| Implemented |
| 6400.114(b) | The provider agency's smoking policy prohibits smoking inside the home. On 3/18/2026 at 1:56PM, a partially smoked cigarette and ashes were inside the toilet in the bathroom in the basement of the home. Additionally, there were cigarette ashes on the floor of the bathroom near the trash receptacle in the bathroom. | Written smoking safety procedures shall be followed. | The violation occurred because the agency's written smoking safety procedures were not followed. On 3/19/2026, the cigarette and ashes were removed immediately, the area was cleaned, and staff were counseled regarding the agency's no-smoking-inside policy and smoking safety procedures. The program manager reviewed the policy with staff assigned to the home. |
03/30/2026
| Implemented |
| 6400.171 | On 3/18/2026 at 1:45PM, a large, uncovered pot containing used cooking oil and food chards at the bottom and sides was on the stove in the kitchen of the home. At 1:50PM, a bowl of ground meat was partially covered with aluminum foil, exposing some of the meat to contaminates, was on the shelf in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The violation occurred because food storage and kitchen sanitation practices were not followed. On 3/19/2026, the uncovered pot containing used oil and food residue was removed, and the exposed ground meat was properly discarded or covered in a sanitary manner. Staff were immediately retrained on safe food storage, handling, and contamination prevention requirements. see the attached certificates. |
03/30/2026
| Implemented |
| 6400.181(d) | Program Specialist #1 did not sign Individual #1's assessment, completed 2/2/2026, prior to sending it to the plan team members on 2/4/2026. | The program specialist shall sign and date the assessment. | The violation occurred because the assessment was distributed before the program specialist completed the required signature and date. On 3/26/2026, the assessment was reviewed, signed, and dated by the program specialist, and the corrected document was maintained in the individual record and reissued to the team as needed. Please review the attached assessment and the email that was sent to the team. |
03/30/2026
| Implemented |
| 6400.32(r)(1) | On 3/18/2026 at 2:02PM, there was a turn locking mechanism on the inside with a thumbnail locking mechanism on the outside of the door leading to Individual #1's bedroom on the second floor of the home. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | 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. | The violation occurred because the bedroom door was equipped with a locking mechanism that did not provide Individual #1 with an accessible method to independently lock and unlock the door. On 3/25/2026, the locking mechanism was replaced (see attached picture) to provide an accessible locking method for the individual. The program manager verified that the individual is now able to independently lock and unlock the bedroom door. |
03/25/2026
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Levothyroxine 88MCG Tablets with instructions to, "Take 1 tablet by mouth daily before breakfast for Thyroid." Individual #1's March 2026 Medication Administration Record reads, "Take 1 tablet (88 MCG Total) by mouth daily." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The violation occurred because the special precaution for administration was not accurately transcribed from the prescription label to the MAR. On 3/19/2026, PDC Pharmacy was contacted, and the MAR was corrected to include the full medication direction, including the requirement that Levothyroxine be administered before breakfast. The program specialist reviewed the MAR for accuracy and confirmed the correction. see the attached E-MAR - Therap- |
04/05/2026
| Implemented |