| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of inspection, the ceiling vent located in the "big bathroom" had a significant amount a dust in it. | Clean and sanitary conditions shall be maintained in the home. | The ceiling vent in main bathroom was taken down, thoroughly cleaned, and re-installed by a maintenance worker from St. Joseph's Center (pictures to follow). |
11/04/2025
| Implemented |
| 6400.112(i) | 112i: The fire drills conducted on 12/8/24 at 2:32 pm, 1/3/25 at 10pm, 3/26/25 at 4pm, 4/15/25 at 1 am, 8/27/25 at 8pm, and 10/3/25 at 3 am did not indicate that a smoke detector was set off during each drill as this section was left blank on the form | A fire alarm or smoke detector shall be set off during each fire drill. | : All agency staff were re-trained and tested on fire drill procedures and properly filling out fire drill paperwork by the Program Coordinator. |
12/01/2025
| Implemented |
| 6400.144 | Individual #1's record had documentation of Individual 1's Eye examination being completed on 10/12/23, and the appointment form noted f/u 2 years, 10/16/25. There is no record or documentation that this 2-year eye follow up appointment in 2025 occurred for Individual #1. The agency stated that the eye provider changed the appointment to 11/5/25, and the Licensing Representative requested documentation on this change on 10/31 via email but was not provided by the agency. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #1 had the appointment cancelled by the provider. At the time of inspection, documentation from the provider was not available to the inspector. The provider did send documentation of the cancelled appointment and said documentation was emailed to the inspection team on 11/3/25 at 4:07 PM. The nursing staff re-trained staff in individual #1's home on completing agency documentation when an appointment is changed and also requesting documentation from the provider that the appointment was moved by their team. |
11/29/2025
| Implemented |