| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not fully completed within the correct time frame of 3-6 months prior to the license expiration or 6-9 months after the last inspection. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Operations Team will update its self-assessment process to complete self-assessments within 3 to 6 months prior to the expiration date of the agency's certificate of compliance by 4/24/26. |
06/30/2026
| Accepted |
| 6400.15(c) | The most recent self-assessment identified violations but did not include a full written summary of the plan of correction/plan to maintain compliance. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Operations Team will update its self-assessment process to complete self-assessments within 3 to 6 months prior to the expiration date of the agency's certificate of compliance by 4/24/26. |
06/30/2026
| Accepted |
| 6400.22(d)(1) | At the time of inspection, Individual #1's cash financial record was not current and up to date. The ending balance in March 2026 was documented as $78.76. However, the cash on hand was $88.21. Staff did figure out what had occurred prior to inspection ending. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Finance Department will enter a "late entry" update on the checkbook ledger to capture the missing deposit. |
04/30/2026
| Accepted |
| 6400.22(e)(3) | Individual #1 spent $17.97 at Bath and Body Works on 12/11/25. There was no receipt. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Team Member responsible for the missing receipt will be retrained by the Manager on the process for maintaining records and supporting financial transactions of the individual by 4/24/26. |
07/31/2026
| Accepted |
| 6400.141(c)(4) | Individual #1 had their hearing screened at the 7/23/25 physical. There is no documentation as to when it was completed in 2024. The 2024 physical documented their ears were checked and that they do not see an audiologist. This does not meet the requirement for a hearing screening having been completed. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Nursing Services Coordinator will update the annual physical template to include hearing and vision by 4/24/26. |
05/31/2026
| Accepted |
| 6400.144 | Individual #1 is to be repositioned every two hours. From June 2025 to the present, there were a total of 139 days that Individual #1 was not repositioned every two hours. Individual #1's bowel movements are to be tracked daily. From July 2025 to December 2025, there were a total of 23 shifts that bowel movements were not tracked.
Individual #1 is prescribed Anti-Diarrheal tablets as a PRN. At the time of the inspection, the medication was not available in the home.
Individual #1 is prescribed Bacitracin to be administered as needed. If it is administered for more than three days with no improvement, the doctor is to be notified. Individual #1 was administered this medication every day from 9/15/25 to 9/22/25. There is no documentation that the doctor was called as required. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Residential Coordinator will retrain team on completing all required documentation. Residential Coordinator will retrain team on Individual #1's SO and documenting effectiveness of PRNs. Residential Coordinator will retrain Manager and Medical Support Professional of Individual #1's home on medication reordering requirements, which includes ensuring that all prescribed medications are available in the home. These will be completed by 4/24/26. |
06/30/2026
| Accepted |
| 6400.32(g) | Per Individual #1's ISP they enjoy going bowling. There were months residential staff did not take them into the community at all and they haven't gone bowling. | An individual has the right to control the individual's own schedule and activities. | An activity calendar will be developed within the home by the Residential Manager that includes community events/activities/preferences of individuals within the home. Team Members will be trained by the Residential Manager on how to use and follow the activity calendar. These will be completed by 4/24/26. |
07/31/2026
| Accepted |
| 6400.34(a) | Staff were able to provide Individual #1's rights from 2025, but not 2024. It is unclear if they were reviewed within a one-year time frame. | 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. | Operations Team will retrain Managers and Program Specialists on the regulation that Individual Rights must be reviewed within a one-year time frame by 4/24/26. |
05/31/2026
| Accepted |
| 6400.166(a)(2) | Individual #1 was prescribed Pseudoephedrine as a PRN beginning in January 2026. The prescriber is not documented on the MARs from January 2026 to the present. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Medical Support Professional at Individual #1's home will update the eMAR to include the prescriber of PRN Pseudophedrine by 4/24/26. |
04/30/2026
| Accepted |
| 6400.182(c) | Individual #1's ISP is not being updated as needed. Their ISP documented they have a device to help them reach items and grab for things. At the time of the inspection, staff reported this is no longer the case. Individual #1 is no longer able to use that device. Individual #1's ISP also documented that Individual #1 has a Tru Link Debit Card for their money. This is not the case. The individual has cash. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist will reach out to the Supports Coordinator by 4/24/26 so that the inaccurate details are removed from the ISP. |
06/30/2026
| Accepted |