| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Service Plan, last updated 8/7/25, explains that "all of the poisons in [Individual #1's] home are locked up. [Individual #1] does not understand danger signs or warning labels." At 2:23 PM on 9/4/25, unlocked and accessible in the storage room located in the attached garage were the following poisonous materials: a one-gallon jug of Eliminator Weed & Grass Killer; a one-gallon jug of Shout Laundry Stain Remover; three one-gallon jugs of Rain-X windshield Wiper Fluid; and a one-gallon jug of Super Tech Bug Remover. | Poisonous materials shall be kept locked or made inaccessible to individuals. | DHS staff will ensure that all poisonous and hazardous chemicals are kept in a secured closet or other locked location at the home at all times |
10/31/2025
| Implemented |
| 6400.66 | At 1:37 PM on 9/4/25, there was no exterior light fixture or sufficient nearby lighting source located outside of the sliding glass doors leading from Individual #2's and Individual #3's bedrooms to the enclosed rear deck for safety and convenience during leisure time in this area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider will insure proper lighting for safety. |
10/31/2025
| Implemented |
| 6400.104 | Individual #1's current assessment, completed on 4/1/25, indicates that "staff would need to provide verbal and physical assistance when evacuating." However, the home's fire department notification letter, dated 5/18/24, was not kept current, as it did not include the following: indication that any of three individuals residing require assistance evacuating in the event of an actual fire; the exact location of Individual #1's bedroom; a description or diagram of the home's general layout; and a general description of Individual #1's mobility needs. | 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 where our individuals sleep. We will also provide a diagram of the home's layout in the event of an emergency. |
10/31/2025
| Implemented |
| 6400.112(c) | According to the written fire drill record submitted from 11/28/24 to 8/21/25, the drill conducted on 8/21/25 did not document whether the fire alarm(s) or smoke detector(s) were operable, as the corresponding field was left blank. [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 takes for the complete evacuation of staff and individuals are recorded. Additionally, the exit route and any issues or concerns regarding problems that arise during the fire drill should be addressed. Operational documentation on all equipment will be completed. |
10/31/2025
| Implemented |
| 6400.113(a) | Individual #1 completed annual fire safety training on 6/14/24, and then again on 8/21/25. | 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 is 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 |
| 6400.142(a) | Individual #1's most recent dental examination was completed on 2/25/25. However, Individual #1's content of records did not include documentation that a dental examination had been completed in 2024. Therefore, annual compliance cannot be measured. [Repeated Violation-11/13/24, et al] | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | 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(e)(1) | Individual #1's current assessment, completed on 4/1/25, 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 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 current assessment, completed on 4/1/25, 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)(10) | Individual # 1's current assessment, completed on 4/1/25, did not include a lifetime medical history, as it was located in a separate record binder entitled, "[Individual #1]: Confidential." Furthermore, because the agency did not provide documentation of when Individual #1's current assessment and lifetime medical history were sent to the plan team, compliance could not be measured. | 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 individual's assessments. The lifetime medical history will be made available to the plan team. |
10/31/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 4/1/25, 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 is with [agency] staff and peers. Programming: [Individual #1] attends···a day program 2 days a week. Services: [Individual #1] receives support coordination···and attends a day program 2 days a week. [Individual #1] resides in a ···group home with 24/7 staffing." | 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 |
| 6400.214(b) | At 2:11 PM on 9/4/25, neither hard nor electronic copies of Individual #3's most current assessment were kept at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| All individual documentation will be securely stored in a locked box and placed in an additional locked area within the home to ensure its confidentiality. |
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, and complete assessments using this form. |
10/31/2025
| Implemented |
| 6400.32(r)(1) | At 1:35 PM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #1 with a unique mechanism in which to lock and unlock their bedroom door. At 1:36 PM on 9/4/25, Individual #2's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #2 with a unique mechanism in which to lock and unlock their bedroom door. At 1:37 PM, Individual #3's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This locking assembly does not provide Individual #3 with a unique mechanism in which to lock and unlock their bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | DHS Site Monitors will be asking each individual to confirm whether they want a lock on the door. Review the Individual and Basic rights. In addition, staff will adjust the locks to be suitable for the individual's ability or, if desired, not lock the mechanism at all. |
10/31/2025
| Implemented |
| 6400.32(r)(4) | At 1:35 PM on 9/4/25, Individual #1's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. At 1:36 PM on 9/4/25, Individual #2's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. At 1:37 PM, Individual #3's bedroom door was equipped with a privacy lock having a pop button on the interior and a thumbnail, straight-edge access point on the exterior. This bedroom door lock mechanism does not allow easy and immediate access by the individual and staff persons 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. Review the Individual and Basic rights. In addition, staff will adjust the locks to be suitable for the individual's ability or, if desired, not lock the mechanism at all. |
10/31/2025
| Implemented |
| 6400.50(a) | Individual #1's annual fire safety training completed 8/21/25, did not include a documented trainer or source for who conducted the training. | 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. | The Provider will maintain the sign-in sheet for each location with the name of the training source, the agenda, date, and length of training. The content will be attached to the sign-in log and agenda. Copies of the certificates will remain in the individual's file. |
10/31/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #1 has not had their medication reviewed by a licensed physician since 4/15/24. [Repeated Violation-11/13/24, et al] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The medication reviews are completed by telehealth every three months. The DHS Provider has been unable to obtain written documentation from the psych provider. DHS has been educated on how to document in the home. DHS will continue to request documentation from the psych provider while documenting the appointment date and time, medication review, and if there are medication changes. |
10/31/2025
| Implemented |
| 6400.166(a)(11) | On 9/4/25, Individual #1's September 2025 Medication Administration Record and corresponding medication label did not include the relative diagnosis or purpose for the prescribed, Venlafaxine HCL ER 150 MG---Take one capsule by mouth every day. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Provider has contacted the pharmacy for complete Medication Administration Records with all required information. The Provider has checked it with the medications on hand and the physician's order. |
10/31/2025
| Implemented |
| 6400.181(f) | The agency did not provide documentation of when Program Specialist #1 had sent Individual #1's current assessment, completed on 4/1/25, to the plan team for an annual review meeting that was held on 7/16/25. Therefore, compliance could not be measured. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist will send the Assessment to the service Coordinator 30 days prior to the ISP meeting and document the date and method of sending. |
10/31/2025
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 8/7/25, contained the following discrepancies between their current assessment, completed on 4/1/25, in the following health and safety skill domains: regarding water safety, Individual #1's Service Plan, last updated 8/7/25, left their ability to swim entirely unaddressed. However, Individual #1's assessment, completed on 4/1/25, indicated, "No," meaning that Individual #1 cannot swim; and regarding supervision, Individual #1's Service Plan, last updated 8/7/25, left supervision within the home completely unaddressed and indicated only the following in terms of supervision in the community: "[Individual #1] requires support under [their] arms···while crossing the street. In contrast, Individual #1's assessment, completed on 4/1/25, stated vaguely that Individual #1 cannot be left unsupervised at home or in the community. | 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 |