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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 9/24/2025 at 11:28AM, at the hot water measured 141°F at the sink in the bathroom on the first floor next to the kitchen. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120 that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The Maintenance staff of the home have adjusted the temperature of the hot water tank to remain at a maximum temperature of 120 degrees (f). |
10/03/2025
| Implemented |
| 6400.52(c)(3) | Program specialist #1's annual training hours for training year from 1/1/2024 to 12/31/2024 did not encompass Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Program Specialist #1's annual training hours for the training year of 2025 has included training that encompasses Individual Rights. This training was completed by Program Specialist #1 in July of 2025. |
07/15/2025
| Implemented |
| 6400.52(c)(4) | Program specialist #1's annual training hours for training year from 1/1/2024 to 12/31/2024 did not encompass Recognizing and Reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Program Specialist #1's annual training hours for the training year of 2025 has included training that encompasses Recognizing and Reporting Incidents. This training was completed by Program Specialist #1 in July of 2025. |
07/15/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | There was no documentation of an unannounced fire drill conducted in the month of January 2022. | An unannounced fire drill shall be held at least once a month. | In response to this violation of 6400.112(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the house managers of the McGuire Memorial community home program will be trained that they are required to hold and document an unannounced fire drill every month at each house that is currently occupied regardless of current conditions and circumstances of the home. These fire drills will be held during normal staffing conditions, held at different times of day and night, different days of the week, and will use alternate exit routes. One ¿sleeping¿ drill will occur every three months. [Training on fire drills, including maximum evacuation time, occurring on various dates, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS.] |
03/09/2022
| Implemented |
| 6400.141(a) | Individual #1, date of admission 6/10/2021, had a physical examination on 8/19/2020; however, the physical examination did not indicate that the individual was free from a communicable disease. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | In response to this violation of 6400.141(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Prior to the admission of any new residents to the McGuire Memorial Community Home program, both the Director of Nursing and the Director of Community Homes will review the most recent physical examination for the prospective resident to ensure completion within 12 months prior to the admission. Both program directors will ensure that this physical examination form is completed in its entirety and contains all necessary information in accordance with the current regulatory guidelines including an indication that the individual is free from all communicable disease. |
03/09/2022
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 06/08/21. The rights document did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, control of and the right to refuse the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | In response to this violation of 6400.34(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, and into the future, when explaining to and informing each individual of their rights, the individual will be informed of the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, door locks in bedrooms and to the main entrance of the home, access to food at any time, and making healthcare decisions. The updated rights will be documented for each individual who resides within our community home program and their guardians, and they will be asked to sign off that they have had these rights explained to them. This will all be completed no later than April 15, 2022. [Updated and signed Individual Rights document, dated 3/28/22, received on 4/4/22 and reviewed 4/19/22. Training, dated 3/29/22, on Individual Rights received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. |
04/15/2022
| Implemented |
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