| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguisher in the attic was outdated. The tag reflects that the extinguisher was last inspected in Oct 2023. This exceeds the time frame. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher in the attic was replaced the day after our inspection (9/25/25). |
09/25/2025
| Implemented |
| 6400.112(g) | The agency completed a sleep fire drill on 4.29.25 and 10.30.24, both occurring at 11:15pm. Fire drills shall be at different times of the day and night. | Fire drills shall be held on different days of the week and at different times of the day and night. | The current Fire Drill Log includes broad timeframes for when drills should happen. To avoid drills being done at the same time each year, we will narrow these timeframes to 3-hour windows or less. For example, the current form lists Sleep Drills between 11pm and 5am twice a year. The updated form will require one drill between 11pm and 1:30am, and the second between 2am and 5am. |
11/01/2025
| Implemented |
| 6400.144 | Individual #6 had his annual physical on 1.20.25. At this appointment his Primary Care Physician (PCP) made a referral for a colonoscopy. The PCP reported his last colonoscopy that was conducted in 2019, revealed a single polyp, grade 1 internal hemorrhoids, and mild diverticulosis. Given these findings, a follow-up colonoscopy was recommended after 5 years. There was no documentation that a colonoscopy has occurred since the referral was made. The agency will provide services for the medical | 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.
| Our Nursing Healthcare Coordinator contacted the Digestive Health Specialist, which performed the colonoscopy in 2019 and noted that no follow-up colonoscopy was needed until 2029 to request that they provide confirmation that a colonoscopy is not needed until 12/2029 as was noted following the colonoscopy and as noted on the response to the PCP's referral that was missing a checkmark on why the colonoscopy referral was denied. A copy of a fax sent by the specialist to the PCP on 9/30/25 noting that this individual is not due for a colonoscopy will be provided as confirmation of the follow-up plan established by the specialist, noting that the next colonoscopy should be scheduled in 12/2029. This fax was retrieved from the individual's hospital electronic patient portal, and includes the note specifically addressed to the PCP. |
09/30/2025
| Implemented |
| 6400.181(a) | Each individual shall have an initial assessment upon admission to the residential home and an updated assessment annually thereafter. Individual #6 had assessments dated 8.8.24 and 8.8.25, however the assessments lacked meaningful information. The assessments provided did not reflect the same level of skills within the assessment and Individual Support Plan (ISP) in several areas, including motor development skills and personal needs. The assessment reflects the individual is independent in many of the areas, whereas the ISP reflects that the individual requires verbal prompts in the same area. Assessments are essential to maximizing growth and development and protect the individual's health and safety. Assessments that lack quality or not individualized and relevant to the person's specific needs can lead to services that lack quality and potentially lead to harm. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Training will be held on 10/23/25 for all Program Specialists and Site Supervisors to reinforce the expectation that each Residential Skills Assessment must include thorough and meaningful information on the individuals' current skill levels as well as establishing relevant recommendations for what services and activities will help individuals both maintain and increase their skills across different domains.
All Program Specialists have also been asked to update every Residential Skills Assessment by 11/30/25 to include this information for all individuals receiving services. |
10/23/2025
| Implemented |
| 6400.181(e)(12) | The annual assessment shall include recommendations for specific areas of training and services. The annual assessments for Individual #6 dated 8.8.24 and 8.8.25 do not include recommendations. The area of the annual assessment reflects to "continue with last years plan" however when reviewing the previous year's assessment, that area of the 2024 assessment also reflects to "continue with last years plan". | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Training will be held on 10/23/25 for all Program Specialists and Site Supervisors to reinforce the expectation that each Residential Skills Assessment must include clear recommendations for training, programming, and services. This helps provide a framework to support individuals based on their needs and build skills in different areas of their lives.
All Program Specialists have also been asked to update every Residential Skills Assessment by 11/30/25 to include this information for all individuals receiving services. |
10/23/2025
| Implemented |
| 6400.181(e)(13)(viii) | The annual assessment for Individual #6 dated 8.8.25 did not document the progress and growth of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | -The Residential Services Skills Assessment was updated on 9/25/25 to include a section that looks at everyone's ability to manage personal property, such as electronics, clothing, and furniture. A screenshot of this section will be provided.
-All the other residents' assessments will be updated by 11/30/2025 to ensure this information is completed for all individuals receiving services. |
09/25/2025
| Implemented |
| 6400.32(h) | The individual has a right to privacy. Individual #6 had a camera located in his bedroom that faced the exit door. Cameras are not allowed in individual bedrooms or bathrooms to maintain their privacy. | An individual has the right to privacy of person and possessions. | It was confirmed with our IT Department on the day of the inspection (9/25/25) that this camera was not active. A screenshot of the video monitoring system was shared with licensing inspectors and management. This screenshot will also be included as confirmation that the cameras were not active. Additionally, as recommended, we removed the camera from the bedroom the day after licensing (9/26/25). Pictures will also be provided as proof of this being done. |
09/26/2025
| Implemented |