| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The written notification to the fire department, dated 5/27/26 states that the individuals living in this apartment can independently evacuate in the event of a fire. In the progress over the last 365 days and current level to evacuate in the event of a fire within 2.5 minutes section of Individual #1's assessment, completed 11/20/25 reads, "[Individual #1] cannot independently evacuate within 2.5 minutes without staff assistance." | 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.
| Upon discovery NFHCS updated the fire notification and send it to the local fire department on July 1, 2026. |
07/01/2026
| Implemented |
| 6400.112(c) | The homes fire drill records indicated that the balcony was used as an exit route on 11/14/25, 1/11/26, 3/26/26, and 5/11/26; however, there is not an egress from the balcony. | 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. | NFHCS recognizes that we cannot correct this violation. |
07/17/2026
| Implemented |
| 6400.181(d) | Individual #1's initial assessment, completed 11/20/25 was not signed by the program specialist. | The program specialist shall sign and date the assessment. | NFHCS recognizes that we cannot correct this violation. [Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/17/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's initial assessment, completed 11/20/25 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | NFHCS recognizes that we cannot correct this violation. [Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/17/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's initial assessment, completed 11/20/25 did not include recommendations of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | NFHCS recognizes that we cannot correct this violation. [Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/17/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1 had a fire safety training on 9/30/24 and then again on 11/20/25. These trainings were not supplemented by site specific information relating to evacuation procedures and designated meeting place. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Upon discovery NFHCS corrected this by training Direct Service Worker #1 on site-specific fire safety training for each NFHCS residential location where the employee is assigned or my be scheduled to work |
07/17/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1 completed 25.75 hours of training on 11/20/2025. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | NFHCS realizes we cannot correct this violation, however staff's training records have been reviewed for accuracy. |
07/17/2026
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's initial assessment, completed 11/20/25 to the individual plan team members on 6/19/26. Individual #1's plan team meeting was on 12/1/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | NFHCS recognizes that we cannot correct this violation |
07/17/2026
| Implemented |