| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home's Fire Department Notification Letter, dated 4/2/25, states: "The [2] individuals are brothers in their 60's: One is fully ambulatory, and the other requires assistance for evacuation." However, the letter does not provide the following: the exact locations of the individuals' bedrooms; and a description or diagram of the home's general layout. | 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.
| The Site Monitor will notify the local FD of the current physical address of the home and the exact locations of the bedrooms that our individuals sleep in. We will also provide a diagram of the homes layout in case of emergency. |
10/31/2025
| Implemented |
| 6400.107 | On 9/4/25 at 10:42 AM, there a portable electric fireplace located in the living room of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| DHS Director will consult with our agency contractor to determine the feasibility of permanently mounting the fireplace. If it is determined that there is not necessary to have such a device mounted, it will be removed in its entirety. |
10/31/2025
| Implemented |
| 6400.112(c) | The home held fire drills on 11/10/24, 12/18/24, 1/30/25, 5/7/25, and 7/26/25 that did not include "AM" or "PM" for the time that they occurred. [Repeated Violation-11/13/24, et al] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Site Monitor and DSP will conduct fire drills and ensure that the date, time of day and the length of time it took for the complete evacuation of staff and individuals. In addition, the exit route and any issues or concerns in regards to problems that exist while completing the fire drill. |
10/31/2025
| Implemented |
| 6400.113(a) | Individual #2's date-of-admission is 4/7/25. However, Individual #2 completed their initial fire safety training on 4/18/25. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | DHS staff will ensure that our individual's fire safety training be completed within the regulatory time period. During this training the individual will be made aware of the evacuation plan and the designated safe area in the event that an actual fire were to occur. |
10/31/2025
| Implemented |
| 6400.141(a) | Individual #2's date-of-admission is 4/7/25. Individual #2's content of records included only a current physical examination completed on 7/23/25, as their content of records contained no documentation regarding the completion of a pre-admission physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | DHS staff will schedule and assist our individuals to complete their physical examination and obtain their documentation of other physical examinations. |
10/31/2025
| Implemented |
| 6400.141(c)(3) | Individual #1's most recent Tdap immunization was completed on 3/5/12. Individual #2 last received a tetanus-diphtheria vaccination on 3/5/12. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | DHS staff will ensure that in addition to the physical examinations that the Tdap immunization is also administered as this is expected to available for our individuals as well as our new individuals. |
10/31/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's physical that was completed on 7/23/25 contained a section for assessment of health maintenance needs; however, this section was left blank. Individual #2's current physical examination, completed on 7/23/25, did not include an assessment of their health maintenance needs, as the corresponding field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | DHS will schedule a physical examination for our individuals and ensure that all of the paperwork is completed in its entirety and that no sections are left blank. These are living documents that include ongoing needs for treatment that need to be addressed. |
10/31/2025
| Implemented |
| 6400.141(c)(12) | Individual #1's physical that was completed on 7/23/25 contained a section for physical limitations; however, this section was left blank. Individual #2's current physical examination, completed on 7/23/25, did not include physical limitations of the individual, as the corresponding field was left blank. | The physical examination shall include: Physical limitations of the individual. | DHS staff will schedule and assist our individuals with their physicals and take an active role when completing the examinations to include when our individuals have any form of physical limitations. |
10/31/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical that was completed on 7/23/25 contained a section for medical information pertinent to diagnosis and treatment in case of an emergency; however, this section was left blank. Individual #2's current physical examination, completed on 7/23/25, did not include medical information pertinent to diagnosis and treatment in case of an emergency, as the corresponding field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | DHS staff will ensure that all pertinent information is provided in our individuals physical and that no sections are left incomplete. |
10/31/2025
| Implemented |
| 6400.141(c)(15) | Individual #1's physical that was completed on 7/23/25 contained a section for special dietary instructions; however, this section was left blank. Individual #2's current physical examination, completed on 7/23/25, did not include special instructions regarding their diet, as the corresponding field was left blank. | The physical examination shall include:Special instructions for the individual's diet. | DHS staff will ensure that no fields are left empty as we will attending the appointments and will assist our individuals. |
10/31/2025
| Implemented |
| 6400.142(d) | Individual #2's date-of-admission is 4/7/25. Their initial dental examination, completed on 5/14/25, did not include documentation of teeth cleaning. | The dental examination shall include teeth cleaning or checking gums and dentures. | The Provider will schedule all dental appointments semi-annually and provide paperwork for the Doctor, stressing the need to document cleaning and examination to ensure that all regulatory requirements are met. |
10/31/2025
| Implemented |
| 6400.181(a) | Individual #1 was admitted to the agency on 4/7/25; however, their initial assessment was not completed until 6/24/25. Individual #2's date-of-admission is 4/7/25. However, their initial assessment was not completed until 6/24/25. | 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. | DHS staff will complete the the individuals initial assessment within the first 30 days of being admitted into our agency if one has not been completed in the last year. |
10/31/2025
| Implemented |
| 6400.181(d) | Program Specialist #1's signature was not dated on Individual #2's initial assessment, completed 6/24/25. | The program specialist shall sign and date the assessment. | DHS staff will complete all of our agency's required sections of the initial assessment. |
10/31/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's initial/ current assessment that was completed on 6/24/25 did not include strengths, as the corresponding field was either missing or unaddressed elsewhere in the document. Individual #2's initial/ current assessment, completed on 6/24/25, did not include their functional strengths, needs, and preferences, as the corresponding fields were either missing or unaddressed elsewhere in the document. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | When DHS staff is completing the individual assessments all sections will be addressed and the pertinent information will be included. |
10/31/2025
| Implemented |
| 6400.181(e)(2) | Individual #1's initial/ current assessment that was completed on 6/24/25 did not include interests, as the corresponding field was either missing or unaddressed elsewhere in the document. Individual #2's initial/ current assessment, completed on 6/24/25, did not include their interests, as the corresponding field was either missing or unaddressed elsewhere in the document. | The assessment must include the following information: The likes, dislikes and interest of the individual. | DHS staff will complete the individual assessments with our individuals and ensure that no fields are left unaddressed. If needed we can also include family members to assist. |
10/31/2025
| Implemented |
| 6400.181(e)(9) | Individual #1's initial assessment that was completed on 6/24/25 had a section for functional and medical limitations; however, this section was left blank. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | When completing the initial assessments for our individuals, DHS staff will include any and all limitations that our new individuals have. |
10/31/2025
| Implemented |
| 6400.181(e)(10) | Individual # 2's initial/ current assessment, completed on 6/24/25, did not include a lifetime medical history, as it was located in a separate record binder entitled, "Confidential Book for [Individual #2]." Furthermore, Individual #2's lifetime medical history was not sent on 8/5/25 to the plan team with their initial/ current assessment. | The assessment must include the following information: A lifetime medical history. | DHS staff will include any and all pertinent lifetime medical history when completing the individuals assessments. The lifetime medical history will be made available to the plan team. |
10/31/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's initial/ current assessment that was completed on 6/24/25 had a section on recommendations for specific areas of training, programming, and services. The section for training states, "Fire Safety training monthly with his DHS staff and peers". The sections for programming and services were left blank. Individual #2's initial/ current assessment, completed on 6/24/25, did not precisely address recommendations for specific areas of training, programming, and services, as the corresponding field read as follows: "Training: Fire safety training monthly with [Individual #2's] [agency] staff and peers." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | DHS staff will include areas of training for our individuals and be specific when doing so. DHS will further explore areas of interest as well. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of Health was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| DHS staff will utilize past records when available and also contact family members when available to more accurately complete these sections. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of motor and communication skills was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | DHS will complete the initial assessments in their entirety. No fields will be left blank and staff will consult family members when applicable to better complete these assessments. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025,"; however, Individual #1's current level of activities of residential living was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | DHS staff will complete the assessments with our individuals and consult with others when applicable in order to better evaluate the needs of our individuals. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of personal adjustment was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | DHS staff will complete the assessments in their entirety and consult with others in order to gather all of the pertinent information. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of socialization was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | DHS staff will complete each part of the assessments in their entirety and provide all pertinent information in all domains. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of recreation was not addressed. Individual #2's initial/ current assessment, completed on 6/24/25, did not address their current level of functioning in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | DHS staff will complete the assessments and address all domains and gather the individuals information from outside sources in order to adequately complete these assessments. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of financial independence was not addressed. Individual #2's initial/ current assessment, completed on 6/24/25, did not address their current level of functioning in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| DHS staff will complete the assessments in their entirety and provide all of the neccessary information. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of managing personal property was not addressed. | 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. | DHS staff will complete the assessments in their entirety and utilize information that is provided by outside sources when applicable. |
10/31/2025
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's initial assessment that was completed on 6/24/25 had a section for progress over the last 365 calendar days and current level. The section was addressed by stating, "New Admission 4/17/2025"; however, Individual #1's current level of community-integration was not addressed. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | DHS staff will complete the assessments in their entirety and access other means of information to do so when applicable. |
10/31/2025
| Implemented |
| 6400.15(b) | The agency used the Department's licensing inspection instrument modified in June 2018 to complete the self-assessment for this home. The current licensing inspection summary instrument for the community homes regarding individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | DHS has begun to use the Department's Licensing inspection form for 2020. |
10/31/2025
| Implemented |
| 6400.182(c) | Individual #2's Service Plan, last updated 8/25/25, contained the following discrepancies between their initial/current assessment, completed on 6/24/25, in the following health and safety skill domains: regarding poisonous materials, Individual #2's Service Plan, last updated on 8/25/25, contained no reference to or language regarding their ability to use or avoid such materials. However, Individual #2's assessment, completed on 6/24/25, provided a score of "Yes/A," meaning that Individual #2 can safely use furniture polish with assistance. All other listed cleaners were marked, "No," indicating that Individual #2 is unable to safely use them; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #2's Service Plan, last updated 8/25/25, stated only that "[Individual #2] does not need protection from heat." However, Individual #2's assessment, completed on 6/24/25, indicated a score of "I," meaning that Individual #2 can independently sense and quickly move away from dangerous heat sources; regarding fire safety evacuation, Individual #2's Service Plan, last updated 8/25/25, did not address their ability to evacuate within 2.5 minutes, as it stated only that "[Individual #2] has good fire safety skills and is able to burn brush at the home without support." In contrast, Individual #2's assessment, completed on 6/24/25, provided a score of "I," meaning that Individual #2 can independently evacuate within 2.5 minutes in the event of a fire; regarding water safety, Individual #2's Service Plan, last updated 8/25/25, explained that "[Individual #2] is able to temper [their] own water," while Individual #2's assessment, completed on 6/24/25, provided a score of "A," denoting that Individual #2 requires assistance to temper their own water; regarding home supervision, Individual #2's Service Plan, last updated 8/25/25, explained that Individual #2 receives 24/7 awake supervision with the requirements of staff always remaining within auditory proximity of Individual #2 and providing intermittent line-of-sight supervision checks every 15 minutes. Individual #2 Service Plan also indicated that Individual #2 has independent time alone in their bedroom. Conversely, Individual #2's assessment, completed on 6/24/25, informed that "[Individual #2] can be unsupervised through the house and that [they] will walk around the yard."; and regarding community supervision, Individual #2's Support Plan, last updated 8/25/25, stated only that "[Individual #2] understands the difference between rural and town traffic. [They] [are] very cautious and always makes sure to watch for traffic." Individual #2's current assessment, completed on 6/24/25, left community supervision entirely unaddressed. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | DHS staff will reevaluate the individuals ability when completing the assessments as the need for accommodations may change based on the level of care that our individuals require. |
10/31/2025
| Implemented |