| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Failure to provide provided care as specified in the individual plan -- Individual #1's assessment dated 1/25/2026 states under section 181e9 that they are a choking risk and should not have both liquid and solids i.e. cereal and soup. Individual #1's menus were reviewed from March 2026 -- May 2026 and they were served cereal for breakfast 10 times and soup/stew 5 times.
Inappropriate use of a restrictive procedure & use of a mechanical restraint -- On 5/10/2026, Individual #1 reportedly fell while secured in a chair at the kitchen table. The chair used by the Individual during meals is a rolling office chair equipped with wheels. The strap employed was a seat belt, which was positioned around the Individual. Staff reported that they are unsure when chair strap was introduced and by whom, but it has been in use for approximately 3-4 months. Upon the discovery of this incident, it was noted that there was no physician's order for the chair strap. The physician's order subsequently obtained on 5/13/2026 does not establish a direct link between the diagnosis and the concerning behavior that necessitates the use of the chair strap. Furthermore, the Individual's plan does not specify any use of the chair strap, nor does it outline the periodic removal of the device to allow for freedom of movement. In the absence of the documentation, the application of the chair strap is classified as a mechanical restraint. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | a) OM (AK) on 5/15/26 retrained DSP Wil's Meal/eating section of ISP. OM (Matt) will train staff again by 6/19/26.
b) OM will create menu for the next 30 days that will incorporate Will's preferences and be specific on the type of soup (i.e. tomato, pumpkin) and type of cereal (i.e. Farina, oatmeal) on the menu. The menu will be developed and posted by 6/19/26. House Manager will train DSP's by 6/22/26.
Immediate Corrective Action
· OM contacted physician on 6/1/2026 to request add diagnosis to Hydrocortisone cream
c) Menus will be developed with clearer descriptive soups and cereal items that match Wil's plan (i.e. tomato soup, pumpkin soup, farina breakfast)
1. OM instructed staff on 5/11/26 to remove the belt from the kitchen chair. This was completed on 5/11/26. However, staff put the belt on the wheelchair and this was the belt that licensing saw on 5/15/26.
2. Program specialist contact PCP for a prescription to utilize a belt for the chair.
3. This was provided to licensing for review and licensing determined this insufficient.
4. Belt was completely removed from the house on 6/2/2026. |
06/22/2026
| Implemented |
| 6400.64(a) | During the physical site walkthrough on 5/15/2026, ODP licensing staff observed the following clean and sanitary concerns:
· A pungent urine odor in the living room, kitchen and Individual #1's bedroom. Staff reported that the Individual's bed is soaked in urine and is contributing to the smell in the home.
· A plastic urinal was located on the living room end table with a yellow cake-like substance in it, which appeared to be dried urine.
· Brown stains which appeared to be feces were observed on the blue shower chair and on the shower wall near the handrail.
· Trash observed in the basement stairwell amongst cobwebs. | Clean and sanitary conditions shall be maintained in the home. | 1. New mattress was purchased on 5/15/2026 by Associate Director and was delivered on 5/15/2026
2. On 5/15/26, the old mattress was moved the garage by DSP and the new mattress was put in bedroom. A new mattress cover was also purchased by compliance and applied to the new mattress. Five extra covers were also purchased by Compliance to be utilized when needed.
3. On 5/15/26 all plastic urinals were cleaned, and moved to bathroom for storage by the DSP. |
12/31/2026
| Implemented |
| 6400.67(a) | At the time of the physical site inspection on 5/15/2026 the following items were observed to not be in good repair:
· The closet door in the spare bedroom was not secured at the bottom of the door.
· The storm-door egress leading from the garage did not close the whole way and was sticking at the top of the door.
· Located in the back patio area, there were two counter height patio chairs which had rips in the seats. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. Maintenance was dispatched to the home on 6/1/26 to begin repairs on the items listed above. Counter height chairs were disposed of. Completion of all items was done by 6/4/2026 |
07/05/2026
| Implemented |
| 6400.144 | · Individual #1's current ISP dated 5/11/2026 states that they are a choking risk, their food needs to be prepared, cut into bit sized pieces and someone needs to feed them their meals. Their assessment dated 1/25/2026 also states that they may not have both liquids and solids i.e. cereal and soup. Faithful Homes LLC reported that the Individual does not have any choking protocol or eating protocol in place.
· Individual #1 has a diagnosis of seizure disorder. The seizure protocol on file is dated 4/12/2023 and states, "Staff should call 911 and have 'Individual #1" seen at the Emergency Room if there is a seizure lasting more than 5 minutes or if any of the following symptoms are observed:" There are no symptoms listed following the seizure statements. Additionally, the protocol does not include the use of the PRN medication, Nayzilam 5mg with provider instructions to use 1 spray into nostril for seizure lasting more than 5 minutes in duration, if no response in 10 minutes use 1 spray in opposite nostril. The protocol appears to be incomplete.
· On 5/10/2026 Individual #1 was treated in the Emergency Room following a head injury. Upon release from the hospital, physician instructions were to follow-up with their family doctor. The Department requested documentation of the follow-up visit with their primary care physician. It was reported that Individual #1 refused the follow-up visit, however as of 5/22/2026, no documentation was provided to the Department that a visit was ever scheduled initially or documentation of the refusal. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 1. Immediate training on the ISP and seizure protocol will occur by the OM to House manager by 6/19/2026. House Manager to the DSP staff will occur by 6/30/2026 and a training sign in sheet shall provide documentation.
2. An updated seizure protocol was sent to the physician which include Nayzilaim 5mg instructions for review and signature on 6/1/2026.
3. Om will be retrained on medical refusal forms by compliance officer by 6/15/2026 and /or how to document on the medical appointment form a refusal by the individual to attend an appointment. OM will train house managers by 6/18/2026. City Milll DSPs will be trained by 6/30/2026 |
07/30/2026
| Implemented |
| 6400.214(b) | At the time of the physical site inspection on 5/15/2026 the current physical exam, assessment and Individual Service Plan were not available. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| · On 5/15, FFH staff transported the current physical exam and the ISP to the home and notified all staff that it had been returned to the home. |
05/15/2026
| Implemented |
| 6400.18(h)(3) | A Department-certified investigator is required to conduct investigations using the process, standard quality and template(s) outline in the current ODP certified investigator's manual. The certified investigator's manual states "during the investigation, the CI should collect all available evidence that can help tell the story of what happened." On 5/11/2026 at 12:45pm it was discovered that staff were utilizing an unapproved mechanical restraint to strap Individual #1 into their chair while at the kitchen table. As of 5/22/2026, the certified investigator had not obtained physical evidence to include a photo of the strap on the Individual's chair that was being utilized in the unauthorized restraint. It was reported that the strap was removed from the home upon the discovery on 5/11/2026 at 12:45 and was not available to the CI at 5:15pm upon the site visit the same day. Faithful Homes LLC reported that it was unknown who removed the strap from the home and where it was placed upon removal. It was returned to the home by 5/22/2026, again unknown which staff returned the strap to the home. Additionally, the witness statements obtained and provided to the Department regarding the use of the restraint do not utilize any question prompting from the CI, but simply a very short statement written by the witnesses. The quality of interviews and lack of physical evidence is below the standard of quality as identified in the ODP's certified investigator's manual. | A Department-certified incident investigator shall conduct the investigation of the following incidents: Abuse, including abuse to an individual by another individual. | 1. The CI will register to retake CI class that will take place on 7/21-7/23 |
07/30/2026
| Implemented |
| 6400.32(c) | On 5/11/2026, it was discovered that Individual #1 was strapped into their chair by staff while sitting at the kitchen table and subsequently fell from the chair and hit their head. Strapping the Individual to their chair is a direct reflection of revoking an individual's right to not be abused or mistreated as this is classified as a mechanical restraint in the absence of a physician's order for the strap and additional documentation required for the intended use of the strap.
On 5/10/2026 Individual #1 was treated at the Emergency Room following an incident when they fell out of their chair while at the kitchen table. Upon release from the hospital, the after-visit directives were to follow up with their family doctor. Faithful Homes LLC reported that Individual #1 refused this visit. There was no documentation provided to the Department to indicate that the primary care physician appointment was ever scheduled or that Individual #1 refused this appointment. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | 1. Either the Doctor refusal form or the medical appointment form will be put in the home for the DSP use. By 6/19/2026 the staff at this home will be trained on the utilization of either form in the event the individual refuses an appointment. Training of the DSP staff will be completed by the House Manager or above by 6/19/2026 and the staff will sign a training sheet confirming the training. The training of the house manager will be done by the operations manager no later than 6/18/2026. |
07/07/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Hydrocortisone .5% cream. There is no diagnosis or purpose for the medication on the March, April or May 2026 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | · OM contacted physician on 6/1/2026 to request add diagnosis to Hydrocortisone cream |
06/30/2026
| Implemented |
| 6400.186 | · Individual #1's current ISP dated 5/11/2026 states that their thermostat must remain at 71 degrees for their comfort. On 5/15/2026, upon ODP licensing staff entering the Individual's home, it was discovered that the home had 3 separate thermostats. The living room thermostat was set to 73 degrees; the kitchen thermostat was set to 72 degrees and the thermostat in Individual #1's bedroom was set to 72 degrees.
· Individual #1's current ISP dated 5/11/2026 states that they are to have an audio monitor in their bedroom to assist staff with monitoring seizures. On 5/15/2026 when ODP licensing staff were at Individual #1's home it was observed that the audio monitor was tucked into a linen stand with towels. The receiver in the living room was not plugged in. The individual was asleep in their bedroom at the time of the home visit.
· Individual #1's current ISP dated 5/11/2026 states that they cannot identify poisonous substances due to visual and sensory impairment. Poisons are to be properly stored in the home, but do not need to be locked. Upon the physical site inspection on 5/15/2026, a gallon jug of Fabulouso was found sitting in the shower stall. | The home shall implement the individual plan, including revisions. | · On 5/15 DSP set all 3 thermostats to 71 degrees. On 5/15 all towels were removed and the monitor was plugged in immediately and worked. All poisonous substances were moved to under the sink on 5/15. |
06/30/2026
| Implemented |
| 6400.207(5)(I) | EIM #9843695 indicates that on 5/11/2026, it was discovered that Individual #1 was being strapped into a chair while at the kitchen table. The report states that the chair and unauthorized straps were removed from the home. On 5/13/2026 a physician's order was obtained authorizing the use of a "chair belt". The order does not provide a statement of the direct correlation between the Individual's diagnosis and behavior of concern which would require the use of the belt. On 5/15/2026 when ODP licensing staff completed an inspection at Individual #1's home, it was observed that Individual #1 has a motorized chair in the spare bedroom which also had a strap/belt on it. Individual #1 utilizes a wheelchair when out in the community. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care. | 1. OM instructed staff on 5/11/26 to remove the belt from the kitchen chair. This was completed on 5/11/26. However, staff put the belt on the wheelchair and this was the belt that licensing saw on 5/15/26.
2. Program specialist contact PCP for a prescription to utilize a belt for the chair.
3. This was provided to licensing for review and licensing determined this insufficient.
4. Belt was completely removed from the house on 6/2/2026. |
07/01/2026
| Implemented |