| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(b) | The agency used a Department's licensing inspection instrument modified in June 2018 to complete the self-assessment of the home on 4/30/26. The current licensing inspection summary instrument for the community homes for individuals with intellectual disability or autism regulations was promulgated in February 2020. | The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. | May 29, 2026- The assessment was completed by the residential director using the current licensing inspection summary instrument required for community homes serving individuals with intellectual disabilities or autism, ensuring compliance with all elements of the Office of Developmental Programs within 6500 regulations. |
06/01/2026
| Implemented |
| 6500.151(e)(2) | Individual #1's assessment that was completed on 1/12/26 does not include dislikes of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses individual's dislikes.
June 1, 2026- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's dislikes to ensure the assessment accurately reflects their preferences and support needs |
06/01/2026
| Implemented |
| 6500.151(e)(12) | Individual #1's assessment that was completed on 1/12/26 does not contain recommendations for specific areas of training, programming or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses recommendations for specific area of training, programming, and services.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding recommendations for specific areas of training, programming, and services to ensure the assessment accurately reflects the individual's needs, preferences, and support requirements. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(i) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Health. | 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that evaluates the individual's progress over the previous 365 calendar days and documents their current health status. This addition helps ensure a comprehensive review of the individual's growth, support needs, and overall well-being.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current health status and health-related developments over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(ii) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Motor and communication skills. | 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. | May 29, 2026 - the Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the last 365 calendar days and current level in their motor and communication skills.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current motor and communication skills over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(iii) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Activities of residential living. | 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of participation in residential activities.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of participation in residential activities and progress made over the previous 365 calendar days. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(iv) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Personal adjustment. | 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of personal adjustment.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of personal adjustment and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's current functioning and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(v) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Socialization. | 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of socialization.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of socialization and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's current functioning, community engagement, and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(vi) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of participation in recreational activities.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of participation in recreational activities and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's interests, engagement, functioning, and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(vii) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of financial independence.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of financial independence and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's financial skills, functioning, and support needs. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(viii) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of managing personal property.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of managing personal property and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's ability to maintain, organize, and safeguard personal belongings, as well as their support needs in this area. |
06/01/2026
| Implemented |
| 6500.151(e)(13)(ix) | Individual #1's assessment that was completed on 1/12/26 does not contain the individual's progress over the last 365 days in following area: Community integration. | 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. | May 29, 2026 -- The Program Director updated the Individual Assessment to include a section that assesses the individual's progress over the previous 365 calendar days and their current level of community integration.
June 1, 2026 -- The Program Specialist reassessed Individual #1 and completed the newly added section regarding the individual's current level of community integration and progress made over the previous 365 calendar days to ensure the assessment accurately reflects the individual's participation in community activities, relationships, access to community resources, and support needs. |
06/01/2026
| Implemented |
| 6500.133(a) | Individual #1 is prescribed Latanoprost 0.005%. At 2:50PM, the bottle of this medication was in its original box, however there was no pharmacy label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | May 21, 2026 -- The Program Specialist obtained a pharmacy label for Individual #1's prescribed Latanoprost 0.005% ophthalmic solution and affixed the label to the medication container to ensure proper identification and compliance with medication administration requirements.
May 29, 2026 -- The Program Specialist provided retraining to staff #1 regarding medication administration requirements, including the prohibition against removing prescription medications from their original labeled containers in advance of scheduled administration.
May 29, 2026 -- The Agency Nurse reviewed medication management procedures with staff #1 and verified understanding of proper medication storage, handling, and administration requirements. |
05/29/2026
| Implemented |
| 6500.133(b) | At 2:41PM, Interviews revealed that every Saturday, Family Living Provider #1 takes one week of Individual #1's medications out of the pharmacy blister pack and puts them into a weekly pill organizer. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | May 29, 2026 -- The Program Specialist provided retraining to staff #1 regarding medication administration requirements, including the prohibition against removing prescription medications from their original labeled containers in advance of scheduled administration.
May 29, 2026 -- The Agency Nurse reviewed medication management procedures with staff #1 and verified understanding of proper medication storage, handling, and administration requirements. |
05/29/2026
| Implemented |