| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2's Service Plan, last updated 10/10/25, stated that "Toxic chemicals are kept in a secure storage in [Individual #2's] home. [Individual #2's] has no awareness of safety issues regarding toxic chemicals. [Individual #2] does not understand the concept of danger signs or warning labels. [Individual #2] would not understand the difference between poisonous substances and food and drink. [Individual #2] requires constant supervision in order to ensure [their] safety." At 1:18 PM, unlocked and accessible in the full bathroom located in the home's bedroom hallway on the main level were the following cleaners: a 32 fluid-ounce spray bottle of Clorox Multi-Surface Cleaner with Bleach; and a 2.8 ounce can of Simply Done Disinfecting Wipes with instructions to contact Poison Control if exposed or ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 11/6/2025 the following items a 32 fluid-ounce spray bottle of Clorox Multi-Surface Cleaner with Bleach; and a 2.8 ounce can of Simply Done Disinfecting Wipes with instructions to contact Poison Control if exposed or ingested. These items located in the full bathroom located in the home's bedroom hallway on the main level were locked up at that time. |
11/06/2025
| Implemented |
| 6400.64(e) | At 1:01 PM on 11/5/25, the trash receptacle filled with refuse in the kitchen, measuring in 18 inches in height, did not have a lid. | Trash receptacles over 18 inches high shall have lids. | On 11/12/2025 the trash receptacle in the kitchen was removed and replaced with a trash can with a lid. |
11/12/2025
| Implemented |
| 6400.72(a) | At 12:59 PM on 11/5/25, the window in the living room located nearest to the home's entry door did not have a screen. At 1:04 PM, the only window in the home's laundry room did not have a screen. [Repeated Violation-12/3/24, et al] | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On 11/14/2025 a screen in the window in the living room located nearest to the home's entry door has been added. In addition a screen has been added to the only window in the home's laundry room. |
11/14/2025
| Implemented |
| 6400.101 | At 1:10 PM on 11/5/25, the storage room where poisons and cleaners were stored and located next to the staff office on the home's main level, had a sliding, retractable door equipped with metal latch secured with a key-operated pad lock on the outside. Therefore, an entrapment area existed within this room. [Repeated Violation-12/3/24, et al] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The poisons are locked. On 11/14/2025 Maintenance replaced the retractable door equipped with metal latch secured with a key-operated pad lock on the outside. The door handle was replaced with a handle that has a locking mechanism that could not allow anyone to be locked from the inside. |
11/14/2025
| Implemented |
| 6400.104 | The home's Fire Department Notification Letter, dated 1/2/25, stated that there are three individuals residing there. However, this letter did not indicate that Individual #1 requires physical assistance in evacuating. According to the written fire drill record submitted from 11/28/24 to 10/29/25, the drill conducted on 1/27/25, documented that Individual #1 is wheelchair bound and, therefore, requires assistance in evacuating. Furthermore, neither the home's Fire Department Notification Letter, dated 1/2/25, nor its attached floor plan, which depicted the home's five total bedrooms, did not provide the exact bedroom location of Individual #1, who requires physical assistance to evacuate, by specifying which bedroom they occupy, as none of the three residing individuals' bedrooms were identified. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Updated Fire Department Notification letter on 11/14/2025 and sent to fire department. This letter now indicates that Individual #1 requires physical assistance in evacuation. The Fire Department noticification letter now has an attached floor plan which depicts the homes five total bedrooms, and the exact bedroom location of individual #1 who requires physical assistance to evacuate. All individual bedroom's are now identified. |
11/14/2025
| Implemented |
| 6400.46(b) | Direct Service Worker #1 completed fire safety training on 6/28/24, and then again on 5/28/25. However, these fire safety trainings were conducted by Trainer #2, who lacked fire safety expert credentials. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Direct Service Worker #1 is no longer employed by UCIP. Therefore, UCIP was unable to make the employee current in 2025. |
11/06/2025
| Implemented |
| 6400.52(c)(1) | On 2/1/24, Direct Service Worker #1 did not complete annual training for the 2024 calendar year in the application of community integration and supporting individuals to develop and maintain relationships, as the material was self-read, and there was no documented trainer. | 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. | Direct Service Worker #1 is no longer employed by UCIP. Therefore, UCIP was unable to make the employee current in 2025. |
11/06/2025
| Implemented |
| 6400.207(5)(II) | At 1:21 PM on 11/5/25, Individual #1's bedroom contained a hospital bed equipped with half-length rails on its left side. The right side of their hospital bed was positioned against the wall. However, the agency did not provide an actual physician's script stating the reasoning for prescribing Individual #1's hospital bed and rails as based on a medical diagnosis. Individual #1's current assessment, completed on 12/4/24, and their Service Plan, last updated 10/3/25, did not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual for periodic relief to allow freedom of movement. [Repeated Violation-12/3/24, et al] | 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: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | UCIP has decided to adopt a non bedrail philosophy. UCIP maintenance has removed bed rails from all UCIP homes. All doctors of individuals that utilized bed rails have been contacted to provide alternate options to bed rails. |
11/25/2025
| Implemented |