| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 receives SNAP/EBT benefits to be used to purchase food items of their choice that are in addition to food staples purchased by the provider and paid for by Individual #1 through room and board.
Receipts indicate that Individual #1 has purchased multiple items that should have been purchased by the provider. A sampling of receipts from the 7/24-7/25 renewal inspection timeframe documented that stuffing, lasagna, spices, chicken, hot dogs, gravy, Swedish meatballs, half a ham, macaroni and cheese, rigatoni, french bread, hamburger, Nutella, corn, cereal, ravioli, frozen shrimp lo mein, sausage, pork tender loin, chicken drums, boneless turkey, cantaloupe, canned soup, watermelon, frozen rolls, broccoli, tater tots, peas, applesauce, oatmeal and Lactaid had been purchased using Individual #1's funds. The individual appears to be purchasing groceries for the home which should be supplied by room and board. | Individual funds and property shall be used for the individual's benefit. | Individual has been fully refunded of all his personal funds that was used to complete essentials food purchase. Moving forward all petty cash receipts will be filed in the Individual¿s financial book. |
08/05/2025
| Implemented |
| 6400.76(a) | One Individual resides in the home. Two dining room chairs were available during the inspection of the home. The one chair at the dining room table was not sturdy enough to be sat upon and appeared to be falling apart when moved. The remaining chair was in use by Individual #1 who was seated in front of a desk playing a video game in the living room. The one dining room chair available was not sturdy as required. | Furniture and equipment shall be nonhazardous, clean and sturdy. | New dining room chairs were bought and delivered for the Individual¿s home. |
08/05/2025
| Implemented |
| 6400.112(g) | Sleep drills are documented as occurring on 2/2/25 at 12:30am and 8/6/24 at 12:30am. All fire drills shall be held at different times of the day and night. | Fire drills shall be held on different days of the week and at different times of the day and night. | A fire drill schedule has been created specific for each home with different date and time of fire drill completion. |
08/05/2025
| Implemented |
| 6400.141(c)(3) | Documentation indicated that Individual #1 had a Tdap completed on 12/15/14 then again on 1/15/25. This is outside of the regulatory time frame. | 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. | CEO has tasked agency nurse with the responsibility of revieing Individuals medical records on a monthly continuous basis to ensure medical oversight of this nature are caught on time and prevented from occurring. |
08/05/2025
| Implemented |
| 6400.141(c)(12) | The section assigned for information pertaining to the limitations or restrictions for activities on the physical dated 6/11/25 for Individual #1 was blank. The physical limitations of the Individual were not identified as required. | The physical examination shall include: Physical limitations of the individual. | Individual¿s # 1 physical form was reviewed and completed by his Primary Care Physician (PCP). The physical form completed indicated information related to the limitations or restrictions for activities. |
08/05/2025
| Implemented |
| 6400.143(a) | Individual #1 is documented to be on a "Diabetic diet" noted on their 6/11/25 physical. The Individual Support Plan last updated on 6/30/25 notes his diet to be "no concentrated sweets (ncs) diet and triglyceride diet." Staff reported and food receipts indicate that Individual #1 is noncompliant with their prescribed diet. Additional information was requested to document provider attempts to train the Individual about the need for health care. No record of the attempts was provided. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Agency Program Specialist has completed a refresher training on the Individual¿s current ISP with all Individual # 1 staff members July 25, 2025, to ensure clear familiarity of the Individual¿s dietary restrictions stipulated in his ISP. |
08/05/2025
| Implemented |
| 6400.211(b)(3) | At the time of inspection, the name, address and telephone number of the person able to give consent for emergency medical treatment was not easily accessible in the home nor found in Individual #1's record. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Agency has created a medical authorization and consent for emergency treatment form immediately after licensing. The form has been signed by Individual # 1 and all pertinent information listed on it. |
08/05/2025
| Implemented |
| 6400.214(b) | Record review at Individual #1's home revealed that documents required to be in the home were not present. The most current copies of Individual #1's physical examination, dental examination, dental hygiene plan and assessment were not in the home as required. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| A copy of the individual #1 records including the physical examination, dental examination, dental hygiene plan and assessment are now in his home. A copy of his medical and permanent record books has been placed in his home. |
08/05/2025
| Implemented |
| 6400.32(r) | At time of inspection there was no lock on Individual #1's bedroom door. | An individual has the right to lock the individual's bedroom door. | A new door lock has been installed in Individual #1 bedroom with a key provided to him and to all his staff members providing him with care. |
08/05/2025
| Implemented |
| 6400.52(c)(1) | Training records for Staff #1 did not contain documentation that training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was completed as required during the 2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff member #1 has completed trainings on person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships July 22, 2025. |
08/05/2025
| Implemented |
| 6400.182(a) | The Individual Support Plan (ISP) last updated on 6/30/25 for Individual #1 indicates that a restirctive plan is in place for sharps. "[Individual #1] has a restrictive procedure plan in place (access to sharp objects) due to [their]unsafe behavior of threatening staff with sharp objects and utilizing sharps to attack staff, as well as a history of aggressive and explosive behaviors. access to sharp objects needs to be restricted to protect [them], the staff, and anybody else around [them] to avoid another event where people are put at risk. [Individual#1] will not be permitted to have unsupervised access to utilize sharp objects, such as knives, razors, scissors, or any other objects or appliances that [they] has actually used or threatened to use as a weapon to harm others. these items will remain in a locked area of the home when not in immediate use. (additional information is located in the behavior support plan/crisis support sections of isp and the full restrictive procedure plan is located at sco and lhss)." The agency reported that the RPP had been lifted some time ago due to meeting the established goals. A behavioral support plan page provided indicates that the sharps restriction was terminated on 3/15/24. The assessment completed by the agency and dated 8/4/24 also indicates that the sharps restriction had been terminated. The Program Specialist is responsible for reviewing and ensuring the accuracy of the ISP. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | On July 28th, 2025, a team meeting was held for Individual # 1 with his entire support team. His ISP discrepancies with regards to his former restrictive procedure plan for sharps was the discussion point and has been removed from his ISP. |
08/05/2025
| Implemented |