| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At 10:02 AM on 2/19/26, located on the basement floor to the right of the stairs was a green garden hose and a dryer exhaust vent pipe that measured approximately two and one-half feet in length with exposed sharp, crimped metal ends, that posed tripping and hazardous conditions. Leaning against the wall behind the stairs in the home's basement was another dryer exhaust vent pipe that measured approximately six feet in length with exposed sharp, crimped meal ends, that posed hazardous conditions. At 10:12 AM, the sewer drain, located at the center of the floor in the home's attached garage, did not have a grate cover and exposed a circular hole, measuring four inches in diameter, that posed a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The garden hose and vent pipe were removed the day of inspection
Maintenance personnel was contacted and the floor/sewer drain cover will be replaced by 3/13/2026. |
03/13/2026
| Implemented |
| 6400.68(a) | On 2/19/26, the home did not have sufficient hot water pressure, as exhibited by the following recorded water temperatures: at 9:58 AM, the hot water temperature at the kitchen sink measured 93.3 degrees Fahrenheit; at 10:20 AM, the hot water temperature at the tub of the full bathroom located on the home's second floor measured 80.2 degrees Fahrenheit; at 10:21 AM, the hot water temperature at the sink of the full bathroom located on the home's second floor measured 77.5 degrees Fahrenheit; and at 10:40 AM, the hot water temperature at the sink of the full bathroom located on the home's first floor measured 67.4 degrees Fahrenheit. | A home shall have hot and cold running water under pressure. | Water temperature returned to 115 within 30 minutes of the licensing inspector leaving the home and that temperature has been maintained. |
03/10/2026
| Implemented |
| 6400.80(b) | At 10:09 AM on 2/19/26, laying in the home's left side yard and located to the left of the basement's only exterior door, were two sheets of aluminum siding, each measuring four feet by two feet in area, with exposed sharp ends that presented hazardous conditions. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The siding was removed the day of licensing. |
03/10/2026
| Implemented |
| 6400.82(e) | At 10:20 AM on 2/19/26, the base of the bathtub located in the full bathroom on the home's second floor did not contain a bathmat or non-slip surface. | Bathtubs and showers shall have a nonslip surface or mat. | A non-slip mat was placed in the upstairs bathroom on the day of licensing |
03/10/2026
| Implemented |
| 6400.104 | The agency did not submit written notification to the local fire department for this home to address the following: the home's address and the exact bedroom location(s) of any individual(s) who require assistance to evacuate in an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter to the local fire departments in the locations of our homes received a letter with the following information:
a. Name of the home
b. The address of the home
c. The municipality of the home
d. A description of the services provided
e. The location of the person's bedroom
f. The capabilities of the person who resides in the home to exit in case of a fire |
03/05/2026
| Implemented |
| 6400.141(c)(14) | Individual #1's date-of-admission is 11/2/25. Individual #1's pre-admission and current physical examination, completed on 4/17/25, did not include medication information pertinent to diagnosis and treatment in case of an emergency, as there was no corresponding field. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A physical form from Supports, Inc will be used for the upcoming physical in April of 2025.
A letter explaining the need for the updated information was sent to the PCP's office |
03/10/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1's orientation training records did not document the trainer source of who facilitated such training in the following required topics and completion dates: the application of person-centered practices on 9/2/25; the application of community integration, individual choice, and supporting individuals to develop and maintain relationships on 9/3/25; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse on 9/3/25; individual rights on 9/3/25; recognizing and reporting incidents on 9/3/25; and job-related knowledge and skills, regarding implementation of the individual plan relative to individual-specific reviews of such service plans on 12/30/25. Direct Service Worker #1's record of annual fire safety training, completed on 9/4/25, did not document the content used, prepared and/or published by a fire safety expert(s). | 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. | Training source has been added to all training records.
The title of the training video has been added to the fire safety training form
|
03/10/2026
| Implemented |