| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | At 11:12AM on 7/1/2026, the electric hot water heater in the hall closet near the front entryway, appeared to be leaking as there was approximately two inches of water standing in the flood ring at the base of the unit. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Upon discovery NFHCS repaired the leak on 7/1/26 |
07/01/2026
| Implemented |
| 6400.112(c) | The records for the fire drills conducted on 5/11/2026 and 6/7/2026 indicated that the balcony was utilized as the exit route; however, the balcony is on the second floor and there is no means of egress from the balcony. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | NFHCS recognizes that we cannot correct this violation |
07/17/2026
| Implemented |
| 6400.181(d) | Individual #1's assessment, completed on 5/27/2026, was not signed by Executive Director/Program Specialist #1. | The program specialist shall sign and date the assessment. | NFHCS recognizes that we cannot correct this violation.[Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/17/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed on 5/27/2026, did not include a Lifetime Medical History. | The assessment must include the following information: A lifetime medical history. | NFHCS recognizes that we cannot correct this violation.[Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/22/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed on 5/27/2026, did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | NFHCS recognizes that we cannot correct this violation.[Immediately and continuing over the next 2 weeks, the program specialist shall audit and update all individuals' current assessment to ensure all required information is included and accurate. (DPOC by AES,HSLS on 7/24/2026)] |
07/17/2026
| Implemented |
| 6400.46(b) | Executive Director/Program Specialist #1 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered on 10/14/2024 and again on 11/29/2025. | 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 my be scheduled to work. |
07/17/2026
| Implemented |
| 6400.50(a) | The training record for Executive Director/Program Specialist #1 training on application of person-centered practices, community integration, individual choice, and assisting individuals to develop and maintain relationships completed 11/18/2025 indicated that the length of the training was 15 hours. Interviews with agency staff revealed that the length of the training was credit hours and not the length of the training. The training record for Executive Director/Program Specialist #1 on the Individual Support Plans completed 5/28/2026; did not include the length of the training. Program Specialist #2, date of hire 5/26/2026, received training on job-related knowledge and skills, to include Individual Support Plan training completed 6/1/2026. The record for this training indicated that the training source was a "Handout." Interviews with agency staff revealed that the Individual Support Plans were self-read, therefore, did not include an acceptable training source. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | NFHCS realizes we cannot correct this violation, however staff's training records have been reviewed for accuracy. |
07/17/2026
| Implemented |