| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not fully completed within the correct time frame of 3-6 months prior to the license expiration or 6-9 months after the last inspection. | 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. | Operations Team will update its self-assessment process to complete self-assessments within 3 to 6 months prior to the expiration date of the agency's certificate of compliance by 4/24/26. |
06/30/2026
| Accepted |
| 6400.15(c) | The most recent self-assessment identified violations but did not include a full written summary of the plan of correction/plan to maintain compliance. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Operations Team will update its self-assessment process to complete self-assessments within 3 to 6 months prior to the expiration date of the agency's certificate of compliance by 4/24/26. |
06/30/2026
| Accepted |
| 6400.110(a) | (repeat violation from the 6/9/25 inspection) At the time of the inspection on 3/11/26, there was not an operable smoke detector in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Facilities installed an operable smoke detector in the attic on the day of inspection by 4/24/26. |
04/30/2026
| Accepted |
| 6400.32(c) | (repeat violation from the 11/12/25 and 12/12/25 investigations) Individual #1 did not have a bowel movement for 9 days between 9/3/25 and 9/12/25 and no medical treatment was sought until the 10th day on 9/13/25. By not seeking medical attention timely, it places the individual at risk for one of the "Fatal Five" conditions of constipation that may lead to serious health complications if not managed properly. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Standing Order at the time of this incident states the following instructions (for Constipation): "Milk of Magnesia (MOM)- take 30 ml by mouth on the 3rd evening as needed with no medium or larger BM. Days 4-8: repeat, if needed. Day 9: if still no BM, contact PCP!" Per the Standing Order, the PCP was contacted on day 9 and Individual #1 received medical treatment. The PCP then changed the Standing Order to state "Constipation: Day 3: Milk of Magnesia (MOM)- take 30 ml by mouth on the 3rd evening as needed with no medium or larger bowel movement (BM). Day 4: Glycerin Adult Suppository- if no medium or larger BM by the 4th evening. Administer glycerin suppository rectally for Constipation. Day 5: If still no medium or larger BM evening of day 5, contact PCP!" Individual's #1's team has been following the updated the Standing Order since that time. On 3/18/26, Individual's #1 attended their annual physical where the PCP signed off on the Standing Order without making any changes to the Constipation section. Nurse will retrain Individual #1's Team on updated Standing Order document for individual #1 by 4/3/26. |
05/31/2026
| Accepted |
| 6400.52(c)(1) | Staff person #10 did not complete the annual training of the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. | 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 person #10 received disciplinary action on February 2, 2026, for not completing required topics as assigned. Staff person #10 completed 2025 annual training of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 3/6/26.Friendship Community's annual training plan shall be updated by the associate director of human resources by 3/30/26 to reflect the following: Annual training shall be competed by September 30 each plan (calendar) year. Team Members who do not complete annual topics by September 30 will receive disciplinary action. Any team members who do not complete annual training by November 30 shall be removed from the schedule until topics are completed |
04/30/2026
| Accepted |
| 6400.165(g) | -Individual #1's psychiatric medication review form from 1/22/26 does not identify the dosages of the prescribed medications.
-Individual #1 is prescribed Diazepam 10 mg to be taken once daily before appointments or procedures for anxiety. On Individual #1's 8/28/25 and 1/22/26 psychiatric medication review forms, this medication was not listed as one of the individual's prescribed psychiatric medications, therefore, there was no documentation of the reason for prescribing the medication, or the need to continue this medication. | 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. | The Manager will update the psychiatric medication review form for Individual #1 to make sure it is accurate and includes dosages and reason for prescribing the medication by 4/24/26. |
04/30/2026
| Accepted |