| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 9/4/25 at 12:33 PM, the cabinet in the basement had a master lock; however, it was not engaged and, therefore, was unlocked, and the following poisonous cleaners were accessible: a can of Lysol Disinfect Spray; a spray bottle of Great Value All-Purpose Cleaner with Bleach; a spray bottle of Wild Harvest All-Purpose Cleaner; a spray can of Febreze Downy Infusions Air Fershner; and a can of Great Value Furniture Polish. The safety precaution section of Individual #1's Service Plan that was last updated on 8/11/25 reads, "[Individual #1] is unable to identify poisonous substances. [They] [have] no understanding of the proper handling/storage of poisonous substances. There is the possibility that [Individual #1] may ingest a poisonous substance if left unattended." | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous material will be kept in a locked cabinet at all times. Key/combination will not be accessible to individuals at any time. |
10/01/2025
| Implemented |
| 6400.64(a) | On 9/4/25 at 12:20 PM, the inside of the oven had dried up food grease at the bottom, and there was a soiled pizza tray on the oven rack with charred food particles. | Clean and sanitary conditions shall be maintained in the home. | The Site monitor and DSP staff will clean the oven after each prepared meal to ensure that it remains clean. |
10/31/2025
| Implemented |
| 6400.73(a) | On 9/4/25 at 11:56 AM, the three outside steps leading to the walkway in the front of the home did not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Provider will install a handrail as per the regulation requiring a handrail for two or more steps. |
10/31/2025
| Implemented |
| 6400.112(f) | The home held fire drills from 11/6/24 through 8/25/25, and the front door was used as an exit route for all monthly drills. The home has alternate exits available. | Alternate exit routes shall be used during fire drills. | The Provider will conduct Fire Drills, alternating the exit designation. |
10/31/2025
| Implemented |
| 6400.141(c)(6) | Individual #1, with a date-of-admission of 5/1/25, did not have a record of a tuberculin skin test ever being completed prior to admission. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | DHS staff will schedule a Tuberculin skin test for our new individuals prior to admission if one less than 2 years does not exist. This will be part of the new individual check list that will be followed. |
10/31/2025
| Implemented |
| 6400.144 | Individual #1 had a physical examination completed on 2/12/25. The healthcare report from the primary care physician that was dated 3/24/25, states that Individual #1 is on a GERD, gluten free, mechanical soft, chopped and ground meat, renal diet with an 1800ml of fluid restriction. This report also notes that Individual #1 is prescribed Thick-It #2 Powder. The physical examination completed on 2/12/25, also states that Individual #1 liquids need to be of thick consistency. On 9/4/25 at 12:11 PM, staff interviews revealed that there was no Thick-It in the home for Individual #1 and that Individual #1 has not been given Thick-It since they were admitted on 5/1/25. Staff interviews also revealed that Individual #1's food is only cut into bite-size pieces and not mechanically softened. | 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.
| DHS staff will consult with our individuals physicians in order to confirm the dietary restriction of our individuals and when adhere to those restrictions. In the event that such restrictions change we will modify and document the changes. |
10/31/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's initial assessment, completed on 6/24/25, did not include strengths, as the corresponding field was 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 complete the individual assessments, all sections will be addressed, and pertinent information will be included. |
10/31/2025
| Implemented |
| 6400.181(e)(2) | Individual #1's initial assessment, completed on 6/24/25, did not include 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, completed on 6/24/25, has a domain for function and medical limitations; however, this domain 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)(12) | Individual #1's initial 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; fire safety training is done monthly. Individual attends TAC and CPS programming. "[Individual #1] reports that [they] [are] satisfied with the services." | 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 also further explore areas of interest. |
10/31/2025
| Implemented |
| 6400.216(a) | On 9/4/25 at 12:38 PM, there was an unlocked cabinet in the basement of the home that contained confidential records from 2014 and 2015 for Individual #2, who is no longer a resident of the agency. | An individual's records shall be kept locked when unattended.
| All individual documentation will be secured in a locked box and placed in an additional locked container to ensure its confidentiality. To further remain in compliance, these documents will be removed from common areas and placed in a secure, designated area. Provider will remove documentation of the former resident. |
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 |
| 6400.18(g) | Enterprise Incident Management #: 9657222 for psychological abuse was discovered on 7/15/25 at 4:00 PM and reported on 7/16/25 at 11:29 AM. The agency assigned Certified Investigator #1 on 7/16/25 at 10:00 AM. However, Certified Investigator #1's first witness statement was not gathered until 7/17/25 at 1:40 PM with the testimony of Individual #1's mother. Furthermore, Certified Investigator #1 did not make a notation in the Certified Investigator's Report about the reason for this delay in capturing testimonial evidence under the corresponding filed entitled, "Summary of Relevant Information from Witness and Attempts at Interview."
Supervisory Note: P. 27/ 6400 RCG (3/15/23 Version): The provider must assign a Department Certified Investigator (CI) no later than 24 hours after discovery of an alleged incident by a staff person. In addition, a CI pursuant to 6400.18(h) is required to collect the first witness statement no later than 24 hours from being assigned to investigate the incident. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | The provider will initiate an investigation of an incident or an alleged incident within 24 hours of its discovery by a staff person. The provider will have a designated person to initiate timely reporting and conduct checks between supervisors to ensure completion. |
10/31/2025
| Implemented |
| 6400.32(r)(4) | On 9/4/25 at 12:26 PM, the inside of Individual #1's bedroom door was equipped with a push button locking mechanism. On the outside of Individual #1's bedroom door, there was no unlocking mechanism for the individual and staff to gain easy and immediate access in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | DHS Site Monitors will be asking each individual to confirm whether they want a lock on the door. In addition, staff will change the locks if the individual chooses to have locks on the door. |
10/31/2025
| Implemented |
| 6400.34(a) | Individual #1, with a date-of-admission of 5/1/25, was not informed and explained individual rights until 5/5/25. | 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. | DHS staff will inform our individuals of their rights at the day of admittance. This will be part of our opening packet that will be made available to staff to better ascertain the needs of our individuals. |
10/24/2025
| Implemented |
| 6400.46(a) | Direct Service Provider #2 completed annual fire safety training on 6/13/24, and then again on 8/22/25. | 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. | DHS staff will attend annual fire safety training and and evacuation processes in order to gain knowledge in assisting our individuals in the event of a fire. During these annual trainings we will ensure before the training is conducted that it covers the use of a licensed fire extinguisher and that our staff are also trained in the use of fire alarms as well. |
10/31/2025
| Implemented |
| 6400.52(c)(5) | Direct Service Provider #2 did not complete annual training for the 2024 calendar year in the following required content area: individual-specific reviews on the safe and appropriate use of behavior support plans. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | DHS staff will complete annual training in order to remain in compliance with our regulatory standards. DHS now has a checklist for our staff that includes the necessary trainings and how often such trainings need to take place for each staff. Trainings that cover working with individuals in need of behavior supports will be completed within the first 30 days of employment and every year following. |
10/24/2025
| Implemented |
| 6400.52(c)(6) | Direct Service Provider #2 did not complete annual training for the 2024 calendar year in the following required content area: individual-specific reviews on the implementation of service plans. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | DHS staff will take part in annual trainings that are provided by management staff that are required by our regulatory standards. DSP staff will be expected to take part in reviewing service plans and how they are to be used in the every day lives of our individuals. |
10/31/2025
| Implemented |
| 6400.163(d) | On 9/4/25 at 12:15 PM, the closet where the medications are being stored had a broken locking mechanism. The medications were being stored in a lock box. However, Individual #1 is prescribed the controlled substance, Lorazepam, which was not double locked due to the broken locking mechanism on the closet door. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | DHS staff will ensure that any and all medications, especially medicines that are controlled substances be locked away and secured in properly installed locations. At any time a lock is broken or faulty this will be addressed that day and the box/structure will be fixed while the medication is monitored by staff. |
10/31/2025
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Clonidine HCL 0.1mg tablet with instructions to take one tablet by mouth every night at bedtime for mood and Clozapine100mg tablet with instructions to take two tablets (200mg) by mouth at bedtime for mood these medications were not initialed as having been administered on 9/3/25 at 8:00 PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Each individuals Medication Log will be followed based upon the physicians orders. DHS staff will initial in the Med log each and every time that medication is administered. |
10/31/2025
| Implemented |
| 6400.182(c) | Individual #1's initial assessment, completed on 6/24/25, indicates that Individual #1 is independent with poisonous materials and that such materials do not need to be locked. Individual #1's Service Plan that was last updated on 8/11/25 reads, "[Individual #1] is unable to identify poisonous substances. [They] [have] no understanding of the proper handling/storage of poisonous substances. There is the possibility that [Individual #1] may ingest a poisonous substance if left unattended. All poisonous substances are kept locked up and kept away from [Individual #1] at all times." Individual #1's initial assessment, completed on 6/24/25, indicates that Individual #1 is independent around heat sources. In the general health and safety section of Individual #1's Service Plan that was last updated on 8/11/25, it reads, "[Individual #1] does not understand the dangers associated with heat sources." Individual #1's initial assessment, completed on 6/24/25, indicates that Individual #1 is independent with fire evacuation. In the fire safety section of Individual #1's Service Plan that was last updated on 8/11/25, it reads, "[Individual #1] has a tendency to panic and become upset when [they] [hear] a loud noise such as a fire alarm / smoke detector. [Individual#1] requires verbal prompting to evacuate a premise in the event of an emergency within 2.5 minutes." | 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 individual's 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 |
| 6400.186 | In the meals/eating section of Individual #1's Service Plan that was last updated on 8/11/25, it reads, "[Individual #1] is prescribed a GERD, gluten free, mechanical soft, chopped and ground meat, renal diet [with] [a] 1.5 liter of fluid restriction diet per nephrologist..[Individual #1] is prescribed Thick-It to be used 4x a day as needed in clear liquids, 6g's per every 4 [ounces] [of] liquids for dysphagia. [Individual #1]'s food is mechanically softened (chopped) due to being a choking risk." Individual #1 had a physical examination completed on 2/12/25. The healthcare report from the primary care physician that was dated 3/24/25, states that Individual #1 is on a GERD, gluten free, mechanical soft, chopped and ground meat, renal diet with an 1800ml of fluid restriction. This report also notes that Individual #1 is prescribed Thick-It #2 Powder. The physical examination completed on 2/12/25, also states that Individual #1 liquids need to be of thick consistency. On 9/4/25 at 12:11 PM, staff interviews revealed that there was no Thick-It in the home for Individual #1 and that Individual #1 has not been given Thick-It since they were admitted on 5/1/25. Staff interviews also revealed that Individual #1's food is only cut into bite-size pieces and not mechanically softened. | The home shall implement the individual plan, including revisions. | DHS staff will follow the physicians recommendations as well as the individuals service plan in its entirety. If for some reason these two should be conflict with each other staff will reach out to management. If the individuals plan or Doctor recommendations should change the instructions will be noted and followed. |
10/31/2025
| Implemented |
| 6400.213(1)(i) | Individual #1's date-of-admission is 5/1/25. Individual #1's content of records did not include their religious affiliation, a photograph that was dated, the next of kin, their Social Security number, their color of hair, color of eyes, and identifying marks. | Each individual's record must include the following information: Personal information, including: (iv) The religious affiliation. | Upon admission, all records for our individuals will be completed in their entirety. We will have a checklist to be followed to identify all pertinent information regarding our individuals. |
10/31/2025
| Implemented |