| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The kitchen sink tested at 127 degrees Fahrenheit during the physical site walk through. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Water Temperature waImmediately:
1. All homes bathtubs and showers will be inspected by staff at house on 3/3/26 for temperature compliance at 120 degrees (not to exceed 122 degrees per RCG)
2. That staff will send a confirming text to Compliance by 5pm that this action item has been completed and a picture of the thermometer reading will also be sent.
3. This text and picture will be stored in FH Share Drive for documentation
Quality Improvement and on-going compliance:
1. The root cause is the frequency of taking the temperatures in the bathtubs and showers
2. A new robust checklist will be utilized to document the temperature at the bathtubs and showers. The checklist will be utilized and signed by the inspecting house staff and signed by house manager for completion. This will be done weekly beginning 3/8/2026 and continue for a period of 52 weeks. At 52 weeks a review will be done by Compliance to determine if this has been effective and whether this process should be continued.
3. Additionally, the frequency of the physical site tool will be increased from quarterly to every other month. This also includes documentation of the temperature of the bathtubs and showers. The site tool will be completed by key leaders of Faithful Homes. This could include Compliance, Associate Director, Program Specialist, Operations Manager, Strategic Development and Compliance and Director.
4. Training on the weekly checklist and Physical site tool will be mandatory for all Operations managers by Compliance and will be completed by 3/7/2026. Additionally, mandatory training will be done by the Operations managers to the house managers. A signature will be required on training sheet to verify training was completed.
5. Weekly, the checklist will be forwarded to operation manager for signature and then provided to compliance for scanning to the share drive and documentation.
Evidence of Completion
1. All documentation will be uploaded to the share drive for inspection
Floors, walls, ceilings and other surfaces shall be in good repair. Associate director alerted maintenance to repaint section of the wall immediately on 1/7/26. Entire wall was repainted by Maintenance on 1/7/2026. Associate director created weekly house walkthrough check list for house managers to complete and turn in to operations managers. This includes checking regulations in the RCG such as floors, walls, and ceilings for them to be in good repair. This will be implemented moving forward. 01/23/2026 Accepted
s tested on 1/7/2026 by maintenance. Water temperature was turned down to under 120 degrees on 1/7/2026. |
01/21/2026
| Implemented |
| 6400.76(e) | A dining room table was not present during the physical site walk through. | In homes serving eight or fewer individuals, there shall be dining tables with seating for all individuals at the same time. | Associate director had table on order prior to walkthrough but table did not arrive in time. Associate director will have table delivered and placed prior to an individual moving to home. |
01/23/2026
| Implemented |
| 6400.82(f) | A trash can was not in the first floor bathroom during the physical site walk through. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Associate director immediately corrected missing trash can on 1/7/26 prior to individual moving into the home. Trash can was placed in bathroom. Immediately:
1. All homes bathrooms will be inspected by staff at house on 3/3/26 for all items
2. That staff will send a confirming text to Compliance by 5pm that this action item has been completed
3. A picture will also be sent of each bathroom in the home
4. This text will be stored in FH Share Drive for documentation
Quality Improvement and on-going compliance:
1. The root cause is an inconsistent routine of inspecting items in the bathrooms, not inspecting frequently enough, needed staff training
2. A new robust checklist will be utilized to review that all items are present. The checklist will be utilized and signed by the inspecting house staff and signed by house manager for completion. This will be done weekly beginning 3/8/2026 and continue for a period of 52 weeks. At 52 weeks a review will be done by Compliance to determine if this has been effective and whether this process should be continued.
3. Training will be mandatory for all Operations managers by Compliance. Additionally, mandatory training will be done by the Operations managers to the house managers. A signature will be required on training sheet to verify training was completed.
4. Weekly, the checklist will be forwarded to operation manager for signature and then provided to compliance for scanning to the share drive and documentation.
Evidence of Completion
1. All documentation will be uploaded to the share drive for inspection |
01/23/2026
| Implemented |
| 6400.111(c) | A fire extinguisher was not in the kitchen during the physical site walk through. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Associate director immediately placed fire extinguisher in kitchen where easily accessible to staff on 1/7/26. |
01/23/2026
| Implemented |