| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff #1 was hired by the provider effective 03/16/2026. Per Staff #1's Staff Record, this staff's initial physical examination took place on 03/18/2026---after the staff's date of hire. This staff did not receive a physical examination within 12 months prior to hire as required.
Staff #3 was hired by the provider effective 03/02/2026. Per Staff #3's Staff Record, this staff's initial physical examination took place on 03/03/2026---after the staff's date of hire. This staff did not receive a physical examination within 12 months prior to hire as required. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff will not be hired and attend New Employee Orientation until the physical exam and testing are completed and all paperwork is returned to HR Director. |
05/15/2026
| Implemented |
| 6400.151(c)(2) | Staff #1 was hired by the provider effective 03/16/2026. Per Staff #1's Staff Record, this staff's initial physical examination took place on 03/18/2026. This initial physical examination noted that a Mantoux test was placed on 03/16/2026 and read negative on 03/18/2026. Tuberculin testing with negative results was not obtained as a part of this staff's physical examination within 12 months prior to hire as required. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff will not be hired and attend New Employee Orientation until the physical exam and testing are completed and all paperwork is returned to HR Director. |
05/15/2026
| Implemented |
| 6400.46(a) | Staff #2 was hired by the provider effective 08/11/2025 and began working with individuals effective 08/27/2025. Per Staff #2's staff training record, this staff first received fire safety training on 08/28/2025---after the staff began working with individuals. Staff must receive training on fire safety topics prior to working with individuals.
Staff #3 was hired by the provider effective 03/02/2026 and began working with individuals effective 03/04/2026. Per Staff #3's staff training record, this staff first received fire safety training on 03/20/2026---after the staff began working with individuals. Staff must receive training on fire safety topics prior to working with individuals. | 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. | All staff shall be trained in Fire safety prior to working with individuals and documentation of the training and date completed shall be noted. |
05/15/2026
| Implemented |