| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 1/15/2026 at 10:31AM, two bottles of Lysol Advanced Power Clinging Gel Toilet Bowl Cleaner were unlocked and accessible in the cabinet under the sink in the bathroom near the kitchen on the first floor of the home. Individual #2's service plan, last updated 10/14/2025, reads, "[Individual #2] is able to read and recognize some safety precautions such as warning signs, poison and danger signs etc, with prompting." Staff interviews also revealed that poisonous substances should remain locked at all times when unattended. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Lysol Gel was immediately removed from the unlocked cabinet under sink and secured in a locked location that is designated for site supplies. |
01/15/2026
| Implemented |
| 6400.67(b) | On 1/15/2026 at 10:22AM, the closet door was removed from the track and leaning against the wall in the corner of the right side of Individual #2's bedroom. Additionally, the metal track was bent preventing the door from being placed onto the track. At 10:37AM, the drain on the right side of the sink was not connected to a pipe causing the water to leak directly onto the floor in the basement of the home posing a slipping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 1/19/2026, CEO reached out to Residential Resources to address the hazards that were reported. These items were previously reported to Residential Recourses. On 1/19/2026, Supervisors of Maintenance for Residential Resources came to self-inspect. On 1/22/26, a follow up email was sent, the repones that the screen, door and the drain will be fixed 1/30/26 |
01/22/2026
| Implemented |
| 6400.72(a) | On 1/15/2026 at 10:21AM, there was no screen in the only window in Individual #1's bedroom on the first floor of the home. At 10:23AM, there was no screen in the window across from the door in Individual #2's bedroom on the first floor of the home. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | On 1/19/2026, CEO reached out to Residential Resources to address the hazards that were reported. These items were previously reported to Residential Recourses. On 1/19/2026, Supervisors of Maintenance for Residential Resources came to self-inspect. On 1/22/26, a follow up email was sent, the repones that the screens and window will be fixed 1/30/26 |
01/22/0206
| Implemented |
| 6400.72(b) | On 1/15/2026 at 10:23AM, the handle on the right side was broken off and removed and the handle on the left side was partially broken off of the window near the closet in Individual #2's bedroom on the first floor of the home. | Screens, windows and doors shall be in good repair. | On 1/19/2026, CEO reached out to Residential Resources to address the hazards that were reported. These items were previously reported to Residential Recourses. On 1/19/2026, Supervisors of Maintenance for Residential Resources came to self-inspect. On 1/22/26, a follow up email was sent, the repones that the screen, door and the drain will be fixed 1/30/26 |
01/22/0206
| Implemented |
| 6400.80(a) | On 1/15/2026 at 10AM, the walkway leading to the front entrance of the home was covered with snow. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | IT was still snowing whenever the walk way was covered. Staff cleaned and salted walk way ensure the area was clear on 1/15/2026 once it was pointed out. The agency contracted lawn care provider will maintain walk-way and area around the home to ensure no obstructions or hazards. |
01/15/2026
| Implemented |
| 6400.32(r)(1) | On 1/15/2026 at 10:20AM, there was a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been provided with a key to lock and unlock the door independently. On 1/15/2026 at 10:22AM, there was a keyed locking mechanism on the outside of the door leading to Individual #2's bedroom. Individual #2 has not been provided with a key to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | On 1/16/2026, Individuals were asked did they want a key to their door and the entrance door and responded "no." The individual civil rights were updated with the responses and signed by the individuals. |
01/22/2026
| Implemented |
| 6400.32(r)(4) | On 1/15/2026 at 10:20AM, there was a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. On 1/15/2026 at 10:22AM, there was a keyed locking mechanism on the outside of the door leading to Individual #2's bedroom. The keys to the bedroom door were not labeled and agency staff did not have the keys on their person while Individual #1 and Individual #2 were present at the home. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | On 1/15/2026, the staff were told to have their keys in their hand. On 1/16/2026, Keys were made and labeled and colored to identify where the belong. |
01/23/2026
| Implemented |
| 6400.163(h) | On 1/15/2026 at 10:46AM, a bottle of Advil with an expiration date of 2/2022 was on the desk in the staff office on the first floor 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. | Compliance Supervisor(CS) removed the expired medication and properly disposed the medication. |
01/15/2026
| Implemented |
| 6400.166(b) | Individual #1's prescribed medication, Trihexyphen was not initialed as administered at 8:00AM on 1/9/2026. On 1/15/2026 at 11:00AM, Individual #1's prescribed medication, Trihexyphen, was already initialed as administered for 8:00AM at 1/16/2026. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The identified staff was retrained on the 7 medication rights(Right Medication, Right individual, Right Dose, Right Time, Right Route, Right Reason, Right Documentation. The staff was retrained on medication policy and procedures and retrained on the regulation 6400.166(b) and subsection (a)(12) and (13) The staff also received a documentation error. The identified staff was observed by agency med trainer completing a medication pass. |
01/23/2026
| Implemented |
| 6400.182(c) | Individual #1's service plan, last updated 10/6/2025, reads, "[Individual #1] is able to have unsupervised time for up to 45 minutes when [Individual #1] goes for walks in [Individual #1's] immediate neighborhood." Individual #1's assessment, completed 4/4/2025, reads, "[Individual #1] has 90 minutes of down time a day [Individual #1] can walk around [Individual #1's] neighborhood. [Individual #1] is not able to be without direct supervision in the community after [Individual #1's] 90 minutes of down time due to safety needs. [Individual #1] has 24/7 supervision of direct care staff while in the community due to safety needs such of crossing streets and stranger awareness." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 1/21/2026, CEO reached out to the Supervisor of the SC by phone/email to address the discrepancy in the ISP. 1/27/2026 an updated Assessment was sent to the SC Supervisor to address changes for Supervision in the community. |
01/27/2026
| Implemented |