| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | At 11:10AM on 7/1/2026, the walkway outside the door in the back of the home was obstructed by overgrown vegetation. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | NFHCS removed the overgrown vegetation. This was corrected on 7/16/26 |
07/16/2026
| Implemented |
| 6400.46(b) | Direct Service Worker #1 was trained in fire safety on 10/17/2024 and then again on 11/28/2025. 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 may be scheduled to work. |
07/17/2026
| Implemented |
| 6400.163(d) | At 11:03AM on 7/1/2026, a single dose packet of Non-Aspirin was unlocked and accessible inside the first aid kit on top of the refrigerator in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | NFHCS corrected by the Residential Coordinator removing the medications from this first aid kit. This fix was in place on 7/1/2026. All First Aid kits in all homes were checked for compliance on 7/1/2026. |
07/01/2026
| Implemented |
| 6400.163(h) | At 11:03AM on 7/1/2026, a single dose packet of Non-Aspirin with an expiration date of 6/2026 was in the first aid kit on top of the refrigerator in the kitchen of the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | NFHCS corrected by the Team Leads removing the medications from this first aid kit. This fix was in place on 7/1/2026. All First Aid kits in all homes were checked for compliance on 7/1/2026. |
07/01/2026
| Implemented |
| 6400.169(d) | Direct Service Worker #1's two most recent trainings in Medication Administration, dated 3/2/2025 and 3/2/2026 did not include the name of the trainer. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Upon discovery, the HR manager, nurse specialist and compliance manger completed an audit of all medication administration records for all current staff authorized to administer medications. Staff will be retrained upon return from vacation. |
07/17/2026
| Implemented |