| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 07/09/26, at 11:05 AM, the mechanical exhaust fan vent cover, located in the home's bedroom hallway, was layered with dust and debris. At 11:20 AM: the vent cover of the mechanical exhaust fan and light combination fixture, located in the home's only other full bathroom, was layered with dust and debris. In addition, there were three black objects, appearing to be dead insects, inside of the fixture's light cover. | Clean and sanitary conditions shall be maintained in the home. | Maintenance Director cleaned the mechanical fan at the home and the interior of the fixture light cover. |
07/10/2026
| Implemented |
| 6400.141(c)(4) | Individual #1 had an annual vision screening performed at their physical examination, completed on 3/12/2025. However, the physician who completed Individual #1's physical examination on 3/26/2026, did not conduct a vision screening and deferred Individual #1 to an optometrist. Individual #1's content-of-records did not include completion of a vision examination by an optometrist or documentation of scheduled appointment for such in 2026. Individual #1's content-of-records contained a handwritten letter, dated "May 2026," indicating that "[Individual #1's] family does not wish at this time for [Individual #1] to have an eye exam, as [Individual #1] does not cooperate and becomes very agitated." Agency interviews conducted at 12:54 PM on 7/8/2026, revealed that Individual #1's sister is their legal guardian. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 was schedule for an eye exam to be completed 7.28.26. Individual #1 refused to go into the building where the eye exam was to occur at that time. Their desensitization plan was updated 7.28.26 to document is refusal and another appointment will is scheduled 8.21.26 to attempt to have the exam completed. |
07/28/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's current, updated assessment, completed on 5/14/2026, did not include recommendations with specific areas of training, programming, and services for implementation, as the corresponding field read exclusively and vaguely, "Continue current programs and services." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1 Assessment was updated on 7/31/26 to include recommendations for specific areas of training, programming and services. |
07/31/2026
| Implemented |
| 6400.52(a)(1) | Direct Service Worker #1 completed 18.53 hours of annual training for the 2025 calendar year on 1/31/2025, as documented on Direct Service Worker #1's College of Direct Supports and Elsevier webinar transcripts. The agency neither provided a log of the actual time Direct Service Worker #1 took to complete such training hours, nor corresponding payroll documentation to verify Direct Service Worker #1's compensatory status when conducting these training hours on 1/31/2025. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Direct Service Worker #1 was paid for 18.80 hours of in-service training on 7/24/26 that should have been paid for training on 1/31/25. Direct Service Worker #1 did not email the HR Specialist as directed in the memo sent out to receive training hours on their paycheck if the training was completed outside of her scheduled shift. Review of Direct Service Worker #1's training file shows that they completed 52.1 training hours for 2025. |
07/24/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 6/11/2026, and their current assessment, last updated 5/14/2026, contained discrepancies in the following health and safety skills domains: regarding home supervision, Individual #1's Service Plan, last updated 6/11/2026, informed that Individual #1 requires 24-hour daily supervision but "is permitted to have independent time in [their] room with periodic checks, as long as [Individual #1] is within hearing distance." In contrast, Individual #1's assessment, last updated 5/14/2026, informed that Individual #1 requires 24-hour daily supervision with visual monitoring during meals but did not specify any periods of independent or alone time in their room. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1 Assessment is updated to include that Individual #1 is permitted to have independent time in their room with periodic checks, as long as Individual #1 is within hearing distance. It was sent to the supports coordinator on 7/31/26. |
07/31/2026
| Implemented |
| 6400.188(d) | At 11:10 AM, 11:06 AM, and 11:19 AM, respectively, on 7/9/2026, there were child-safety locks affixed upon the cabinets underneath the kitchen sink as well as underneath the sinks in both of the home's bathrooms to secure poisonous materials. Individual #1's date-of-birth is 7/5/1958. Individual #2's date-of-birth is 8/12/1955. Individual #3's date-of-birth is 12/12/1942. Such child-safety locks are not age appropriate, and the residing individuals do not have behavior support plans or restrictive procedure plans with provisions for such locks. | The home shall provide services that are age and functionally appropriate to the individual. | Maintenance Director removed the child locks from the cabinets underneath the kitchen sink as well as underneath the sinks in both of the home's bathrooms. A review of all homes was completed on 7/10/26 to ensure that services provided are age and functionally appropriate to the individual. |
07/09/2026
| Implemented |