| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment of the home, completed by the agency on 4/18/2025, did not address regulations 6400.151a-152c and 6400.165g. These sections were left blank. [Repeated violation: 9/25/2024 et al] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| LIIs will be completed by Program Specialists between 2/23/26 and 3/23/26. Director and QCC will review by 4/15/26 to ensure completion. Shared calendar invites have been created for both timeframes. |
10/13/2025
| Implemented |
| 6400.67(a) | On 9/25/2025 at 12:52am, the flooring in Individual #1's bedroom was observed with gapping between the laminate planks. Two planks near the middle of the bedroom floor were also chipped on the edges and the unfinished portions of the laminate plank had been exposed. | Floors, walls, ceilings and other surfaces shall be in good repair. | Supportive Housing Management, homeowner, is in the process of developing a plan with a plumber and contractor to address the flooring in Individual #1's bedroom. |
10/13/2025
| Implemented |
| 6400.106 | The furnace in the home was cleaned and inspected by a professional furnace cleaning company on 4/18/2024 and then again on 9/23/2025. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace inspections will be scheduled by the Director of Facilities 10 months from the date of the previous inspection. A reminder has been added to shared calendars including the QCC, Director of Residential, Executive Director and CFO. |
10/13/2025
| Implemented |
| 6400.112(c) | The record for the fire drill conducted on 1/12/2025 did not include the time the drill was conducted or the length of time it took for the evacuation. The record for the fire drill conducted on 3/17/2025 did not include the time the drill was conducted or the length of time it took for the evacuation. The record for the fire drill conducted on 5/15/2025 did not indicate the time the drill was conducted. The record for the fire drill conducted on 6/20/2025 did not indicate the time the drill was conducted. The record for the fire drill conducted on 8/16/2025 does not indicate the time the drill was conducted.
The record for the fire drills conducted on 4/13/2025 and 6/20/2025 indicated that the garage door was the evacuation route that was utilized; however, the garage of this home did not contain a man door, it only contained an overhead car door. [Repeated violation: 9/25/2024 et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | An overnight fire drill will be conducted by the 15th of the month. |
10/15/2025
| Implemented |
| 6400.112(d) | The fire drill conducted on 9/13/2024 had a documented evacuation time of 3 minutes and 0 seconds. The fire drill conducted on 10/1/2024 had a documented evacuation time of 3 minutes and 0 seconds. The fire drill conducted on 4/13/2025 had a documented evacuation time of 2 minutes and 50 seconds. The fire drill conducted on 5/15/2025 had a documented evacuation time of 3 minutes and 0 seconds. The fire drill conducted on 6/20/2025 had a documented evacuation time of 3 minutes and 0 seconds. The fire drill conducted on 7/10/2025 had a documented evacuation time of 2 minutes and 35 seconds. The home does not have documentation of an extended evacuation time written by a fire safety expert within the last year. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A meeting with a local fire inspector was held on 9/29/25 to begin the process of inspections of all homes, with the first inspection being completed on the same date. Once all homes are completed, information and recommendations will be reviewed. |
09/29/2025
| Implemented |
| 6400.112(e) | For the fire drill records that were reviewed from 9/26/2024 to 8/15/2025, the only drill that was conducted during sleeping hours was held on 4/13/2025. [Repeated violation: 9/25/2024 et al] | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill will be conducted by the 15th of the month. |
10/15/2025
| Implemented |
| 6400.141(a) | Individual #1's physical examinations were completed on 4/30/2024 and then again on 7/17/2025. [Repeated violation: 9/25/2024 et al] | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1's physical was completed on 7/17/25. |
10/13/2025
| Implemented |
| 6400.141(c)(4) | Individual #1, date of admission 10/1/2024, did not have a vision or hearing screening completed prior to admission. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 had a physical completed on 7/17/25, which included a vision and hearing screening. |
07/17/2025
| Implemented |
| 6400.165(g) | Individual #1, date of admission 10/1/2024, is prescribed medications to treat symptoms of psychiatric illnesses to include Chlorpromazine 100mg oral tab which is prescribed for mood disorder. Individual #1 does not have documentation that their psychiatric medications have been reviewed since their admission. [Repeated violation: 9/25/2024 et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | An appointment with Individual #1's PCP will be scheduled for a psychiatric medication review. |
10/31/2025
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Polyethylene Glycol 3350 Powder. On 9/25/2025 at 12:32pm, the September 2025 medication administration record instructed to "take 17 G by mouth daily as needed for constipation" while the pharmacy issued medication label instructed to "Mix 17 grams in 8oz water/juice and drink by mouth once daily as needed for constipation." The September 2025 medication administration record did not include special precautions to mix the medication in 8oz of water/juice as indicated on the pharmacy label. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | Individual #1's Polyethylene Glycol 3350 Powder was updated on the MAR on 10/9/25. |
10/13/2025
| Implemented |
| 6400.166(b) | On 9/25/2025 at 12:30pm, it was observed that the following medications were not initialed by staff when they were administered to Individual #1: Certavite Tab Senior, Vitamin B1 Tab 100mg, and Vitamin D3 2000 IU on 9/6/2025 at 8:00am; Chlopromaz Tab 100mg, Docusate Sod Tab 100mg, and Lorazepam Tab 0.5mg on 9/12/2025 at 8:00pm; Lorazepam Tab 0.5mg on 9/7/2025 at 8:00pm; and Lorazepam Tab 0.5mg on 9/12/2025 at 8:00pm. [Repeated violation: 9/25/2024 et al] | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff working in the home will be retrained on the 15 Steps of Administration, which includes documentation. |
10/31/2025
| Implemented |
| 6400.167(a)(1) | On 9/25/2025 at 12:30pm, it was observed that the following medications were not administered to Individual #1 as prescribed: Docusate Sod Tab 100mg, Fluoxetine Cap 20mg, and Senna Tab 8.6mg on 9/6/2025 at 8:00am; Chlorpromaz Tab 100mg and Docusate Sod Tab 100mg on 9/2/2025 and 9/7/2025 at 8:00pm. [Repeated violation: 9/25/2024 et al] | Medication errors include the following: Failure to administer a medication. | Individual #1's service coordinator was notified via email of the omission on 10/9/25. |
10/31/2025
| Implemented |
| 6400.183(c) | Individual #1's record did not include the list of persons who participated in the individual plan meeting. Individual #1 is funded through the Community Health Choices Waiver. According to Senior Residential Homes Manager #1, because Individual #1 does not have a traditional Supports Coordinator, the list of annual team meeting attendees was not kept. | The list of persons who participated in the individual plan meeting shall be kept. | An email was sent to Individual #1's service coordinator requesting a list of team members present for the annual meeting on 10/9/25. |
10/31/2025
| Implemented |
| 6400.207(5)(III) | On 9/25/2025 at 12:50pm, Individual #2's bed contained full bilateral bed rails that restricted the movement or function of the individual's body. The agency had not obtained a prescription order for the bedrails from Individual #2's medical practitioner. Individual #2's most current assessment, completed 6/30/2025, does 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. [Repeated violation: 9/25/2024 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: Protection from injury during a seizure or other medical condition, 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. | The PCP for Individual #2 was contacted on 9/24/25 to request an order for bedrails if deemed necessary. Due to no response, a telehealth appointment was scheduled for 10/28/25 to discuss the order. Once received, the individual's assessment will be updated accordingly and emailed out to the team, with a request to update the plan to reflect the changes. |
10/31/2025
| Implemented |