| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At 1:01 PM on 7/30/25, the interior ceiling finish of the microwave was covered throughout in several areas with oxidation and delamination. | Clean and sanitary conditions shall be maintained in the home. | On August 1 2025, a new microwave was purchase and the old microwave was taken out. On August 7, 2025 The 6400 Supervisors and Program Directors were retrained on 6400.64 in the Regulatory Compliance Guide Chapter 6400. |
08/01/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment, completed on 3/15/25, did not address their preferences, as there was no corresponding field or relative content. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The Program Specialist did an addendum to the Individuals assessment (3-15-25) on July 31, 2025 to include the Individuals Preferences. The Program Directors were trained on August 5, 2025 in Assessments in IDD on the Relias platform. |
07/31/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's current assessment, completed on 3/15/25, did not address their current skill level in the area of financial independence and Individual #1's ability to manage their own money, as the corresponding field read: "[Individual #1's] mother currently provides [their] spending money. [Agency #1] has applied for SSI and is working on becoming [Individual #1's] Representative Payee." | 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.
| The Program Specialist did an addendum to the Individuals assessment (3-15-25) on July 31, 2025 to include the Individuals Financial Independence. The Program Specialist will completed an online training in the Relias Platform entitled ¿Assessments in IDD¿ on August 5, 2025. |
07/31/2025
| Implemented |
| 6400.195(a) | Individual #1's Service Plan, last updated 7/24/25, states the following in regard to sharps: "Because of past behaviors involving [Indivdual#1's] suicidal ideations and threatening to hurt others, such as siblings, teachers, therapists, and peers, sharps and hazardous objects must be carefully stored." At 1:15 PM on 7/30/25, scissors, knives, and all other sharp objects were locked in a closet located in the bedroom hallway on the home's main level. However, Individual #1 does not currently have a restrictive procedure plan approved by the human rights team, limiting access to these sharp objects. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | On July 30, 2025, the program specialist contacted the behavioral specialist who developed a restrictive plan addressing the individuals¿ needs for sharps to be secure. The plan was submitted to the Human Rights committee on July 31, 2025 and approved. The staff, supervisor, program specialist and program director were trained on the newly approved for the restrictive procedure plan. |
07/31/2025
| Implemented |