| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The stairs leading to the attic of the home did not have a handrail as required.
The stairs leading to the bilco doors in the basement did not have a handrail as required. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Handrails have been installed both in the stairs leading to the attic as well as those leading to the Bilco doors. |
07/01/2026
| Implemented |
| 6400.144 | On 3/16/26 Individual #1 was instructed to complete a DEXA scan after 4/2/26 and an echocardiogram. The echocardiogram was completed on 4/22/26 but as of 6/17/26 the scan had not been completed or scheduled as prescribed. | 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.
| The agency would like to note that the individual's DEXA scan was scheduled on March 31, 2026, for July 23, 2026, following the physician's recommendation that the test occur after April 2, 2026. Documentation verifying the scheduled appointment was submitted to inspectors via email on June 18, 2026, in response to the request discussed during the exit conference. |
07/01/2026
| Implemented |
| 6400.46(a) | Documentation of fire safety training for Staff #1 was dated 9/4/24. Documentation of training for 2025 was requested and not received. Staff #1 was not trained in fire safety for the 2025 year. | Program specialists and direct service workers shall be trained before working with individuals 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. | Staff #1 was on an extended FMLA leave. As a result of the employee's inactive status in the Learning Management System, the required training was automatically removed and replaced with training assignments for the following year upon the employee's return. A tracking sheet has been developed to track employees on extended leaves and upon return, training assignments will be reviewed to ensure employees complete all required training. |
07/01/2026
| Implemented |
| 6400.52(c)(3) | There was no documentation to illustrate that Staff #1 had training on Individual Rights as required during the 2024-2025 training year as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 was on an extended FMLA leave. As a result of the employee's inactive status in the Learning Management System, the required training was automatically removed and replaced with training assignments for the following year upon the employee's return. A tracking sheet has been developed to track employees on extended leaves and upon return, training assignments will be reviewed to ensure employees complete all required training. |
07/01/2026
| Implemented |