| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 1/8/2026 at 11:09AM, the hot water temperature measured 126.8F at the sink in the kitchen of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | - On 1/8/26, the Residential Director contacted the Maintenance Manager to report to the 117 West Metzger Avenue home to conduct another water temperature test at the kitchen sink. The Maintenance Manager reported a temperature reading of 123.1 when the hot water was running. The Maintenance Manager reported the findings to the Residential Director and recommended adjusting the hot water tank to a lesser temperature, in which the Residential Director agreed. The Maintenance Manager adjusted the thermostat setting on the hot water tank down to bring the water temperature of the house into Code 63(a) compliance of less than 120 degrees Fahrenheit.
- On 1/9/2026, the Maintenance Manager reported to the Vogel house at both 9:27 AM and 2:45 PM to take follow-up readings of the water temperature at the kitchen sink. The Maintenance Manager got a reading of 117.9 (9:27 am) and 118.5 (2:45 pm), which verified compliance to Code 63(b) of less than 120 degrees Fahrenheit. |
01/09/2026
| Implemented |
| 6400.112(d) | The provider agency's home was evaluated by a fire safety expert, and the fire evacuation time was extended to four minutes. The fire drill held during sleeping hours on 10/26/2025 had an evacuation time of four minutes and thirty-one seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | - On 1/12/26, an in-service meeting was held at the program office. The Program Supervisors and Program Coordinators attended the meeting that was facilitated by the Residential Director and CEO. Compliance to Code 112(d) was discussed in detail regarding compliant fire-drill exit times, and in particular the approved extended exit time of four minutes at the 117 West Metzger home.
- On 1/21/26, a house meeting for all staff assigned to work at the Metzger home will attend a mandatory house training. The assigned Program Supervisor will facilitate the meeting and review Code 112(d) with all staff and verify/ review the Metzger house specific extended evacuation time of 4 minutes. Program Supervisor will review the process of recording a Fire drill time into the Setworks computer system with staff. The Program Supervisor will review the process of alerting the Program Supervisor, should the drill exceed the four-minute mark, in which another drill will be completed to ensure compliance to Code 112(d). Any further issues with compliant evacuation times will be reviewed by the Program Supervisor, Residential Director, and CEO and further action will be taken to ensure the safety of the individuals at the Metzger home. |
01/21/2026
| Implemented |
| 6400.141(c)(3) | Individual #1 had a Tetanus immunization most recently completed on 9/9/2014. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | - On 1/8/26, the Residential Director reached out to the Clinical Director and assigned Program Coordinator to schedule a Tetanus immunization to be completed as soon as possible for Individual #1.
- The assigned Program Coordinator contacted Individual #1's PCP and scheduled an appointment to administer the Tetanus immunization on 1/21/26, which will bring Individual #1 in compliance for Code 141(c)(3). |
01/21/2026
| Implemented |
| 6400.141(c)(8) | Individual #1, date of birth 2/7/1981, had a mammogram on 4/25/2023 and then again on 12/16/2025. Individual #1 is to have annual mammogram screenings based on the following orders: "based on your breast tissue density, age and individual risk factors, annual screening mammography or combination screening mammography and tomosynthesis are recommended for you." | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | - On 1/13/2026, the Clinical Director reviewed the active mammogram orders for Individual #1 (annually) with the assigned Program Coordinator. The Program Coordinator will note the active annual mammogram orders during the appointment audit that will be completed by 1/30/26 by all agency Program Coordinators and reviewed by the Program Supervisors, Residential Director, and Clinical Director. This will ensure no further annual mammograms are missed for Individual #1 moving forward, per her physician orders. |
01/13/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 10/31/2025, did not include the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | - On 1/12/2026, an in-service meeting was held at the program to review Code 141(c) with the Clinical Director, Program Coordinators, and Program Supervisors. The Residential Director and CEO reviewed and explained the policy of having a completed annual physical- all areas of the physical form. All parties agreed to implement and adhere to Code 141(c) on upcoming annual physical appointments. These appointments are completed by the Program Coordinators and/ or the Clinical Director if necessary. All parties signed accordingly to verify they attended the in-service training, reviewed the code, and will implement immediately to best serve our individuals and ensure compliance with proper completion of the annual physical form. |
01/12/2026
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination on 8/29/2024 and then again on 9/25/2025. | 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. | - On 1/9/26, the Residential Director contacted the Clinical Director to verify no other dental appointments occurred between 8/29/24 and 9/25/25 for Individual #1.
- On 1/9/26 the Clinical Director contacted the assigned Program Coordinator to review appointments on record and not any dental appointments between designated time frame for Individual #1. Program Coordinator identified a dental appointment occurred on 3/13/25 and a from was obtained from the records of the dental office that examined Individual #1 on 3/13/25, which returns Individual #1 beck into compliance regarding Code 142(a). |
01/09/2026
| Implemented |
| 6400.144 | Individual #1, date of birth 2/7/1981, had a gynecological examination on 3/8/2024 with follow up instructions to "verify IUD placement 11/2016. If so, return in November for removal/replacement." Staff interviews revealed that Individual #1 did have an IUD device placed in 2016 that should be replaced after eight years. Individual #1 has not been to the gynecologist since 3/8/2024. | 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.
| - On 1/9/26, the Residential Director contacted the Clinical Director to address the Code 144 non-compliance of Individual #1 and explained the specific issue- IUD removal past due for Individual #1.
- On 1/9/26, the Clinical Director contacted the assigned Program Coordinator for Individual #1 to address Code 144 and the need to be seen as soon as possible by Individual #1's gynecologist to address the IUD removal issue and bring Code 144 back into compliance.
- On 1/9/26, the Program Coordinator contacted the gynecologist office of Individual #1, explained the issue (IUD past due to be removed) , and scheduled Individual #1 the earliest appointment to be seen which was 3/13/26. Program Coordinator also got Individual #1 on the cancellation list at the gynecologist office to be seen before scheduled appointment, if possible. |
03/13/2026
| Implemented |
| 6400.216(a) | On 1/8/2026 at 12:11PM, binders containing Individuals #1's, #2's, #3's and #4's service plans and assessments were unlocked and unattended in a crate under the staff desk in the dining area of the home. | An individual's records shall be kept locked when unattended.
| - On 1/9/26, assigned Program Supervisor reported to the 117 West Metzger house to complete an audit of personal information and forms pertaining to all individuals that reside at the Metzger home. The Program Supervisor verified all service plans, assessments, and other forms containing personal and confidential information were locked safely and secure in the appropriate filing cabinet beside the staff desk, which brought Code 216(a) back into compliance. |
01/09/2026
| Implemented |
| 6400.163(d) | On 1/8/2026 at 11:26AM, a bottle of DG Cold and Flu Severe liquid cold medication was unlocked and accessible at the top of a bag on the floor of the unlocked staff room on the first floor of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | - On 1/8/26, assigned Program Supervisor reported to the 117 West Metzger home to conduct an audit pertaining to Code 163(d) and specifically the staff room door on the first floor of the home. The Program Supervisor verified the staff door was appropriately locked, thus placing the 117 West Metzger house back in compliance with Code 163(d). |
01/08/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication for symptoms of a psychiatric illness. Reviews of Individual #1's psychiatric medications were completed on 12/26/2024, 7/3/2025 and 10/16/2025. | 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. | -- On 1/12/26, an in-service was held with the Program Coordinators and Program Supervisors. The Residential Director, CEO, and Clinical Director hosted the in-service. Code 165(g) was reviewed with all parties present and both the Program Coordinators and Program Supervisors signed the in-service attendance sheet verifying that Code 165(g) was reviewed, explained, and they will adhere to the policy effective immediately with scheduling quarterly psychiatric evaluations within the allotted three month (90 days) specified regulatory time-frame. |
01/12/2026
| Implemented |
| 6400.166(a)(4) | Individual #1's January 2026 Medication Administration Record does not include the name of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(5) | Individual #1's January 2026 Medication Administration Record does not include the strength of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(6) | Individual #1's January 2026 Medication Administration Record does not include the dosage form of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(7) | Individual #1's January 2026 Medication Administration Record does not include the dose of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(8) | Individual #1's January 2026 Medication Administration Record does not include the route of administration of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(9) | Individual #1's January 2026 Medication Administration Record does not include the frequency of administration of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(10) | Individual #1's January 2026 Medication Administration Record does not include the administration times of Benzonatate 100MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.166(a)(11) | Individual #1's January 2026 Medication Administration Record does not include the diagnosis or purpose of Benzonatate 100MG. | 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. | - On 1/8/2026, the Residential Director contacted the Clinical Director to explain and address the violation of Code 166(a)(4-11) pertaining to Individual #1 and her Benzonatate 100 MG that was present in her house on 1/8/26, but not present on her MAR.
- On 1/8/2026, the Clinical Director reviewed the electronic MAR via the QuickMAR computer software for Individual #1 and identified the Benzonatate 100MG as a PRN medication that was prescribed for 10 days on 12/12/25- 12/22/25 and confirmed it was discontinued on 12/22/25.
- On 1/8/2026, the Clinical Director reported to the 117 West Metzger Road home and appropriately removed the Benzonatate 100MG, which put Individual #1 medications and MAR back into compliance for Code 166(a)(4-11). |
01/08/2026
| Implemented |
| 6400.181(f) | The Program Specialist #1 provided Individual #1's assessment, completed 7/2/2025 to the plan team on 8/28/2025 for the Individual Plan Meeting held on 8/27/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | - On 1/12/26, an in-service training was held with the Program Coordinators and Program Supervisors at the program office. The Residential Director, CEO, and Clinical Director hosted/ facilitated the in-service. Code 181(f) was reviewed with all parties present and both the Program Supervisors (Program Specialists) signed the in-service attendance sheet verifying that Code 181(f) was reviewed, explained, and they will adhere to the policy effective immediately regarding sending the annual assessment to all individual team members, including the assigned supports coordinator, at least 30 calendar days prior to the annual ISP. |
01/12/2026
| Implemented |
| 6400.186 | On 1/8/2026 at 11:41AM, Individual #2 was alone in the bedroom, lying in bed with a plate of food on the individual's chest. There was no staff in the bedroom with Individual #2. Individual #2's service plan, last updated 12/29/2025, reads, "[Individual #2] requires monitoring when eating food. [Individual #2] needs to be within arms-reach when eating to ensure health and safety." | The home shall implement the individual plan, including revisions. | - On 1/8/26, assigned Program Staff reported to the 117 West Metzger Avenue home and reviewed/ retrained staff that were present on 1/8/26 at 11:41 am regarding the mealtime supervision section of the Individual #2's ISP ("[Individual #2] requires monitoring when eating food. [Individual #2] needs to be within arms-reach when eating to ensure health and safety.") Staff agreed to implement immediately and a full review of Individual #1's ISP will be conducted at the mandatory house meeting for all assigned residential staff on 1/21/26.
- |
01/08/2026
| Implemented |
| 6400.207(5)(II) | On 1/8/2026 at 11:35AM, there were partial bedrails on each side of the bed in Individual #1's bedroom. Individual #1's assessment, completed 7/2/2025, and service plan, last updated 1/6/2026, did not include information about the use and periodic removal of the bedrails. At 11:41AM, there were full bedrails on each side of the bed in Individual #4's bedroom. Individual #4 does not have physician's orders for bedrails. Individual #4's assessment, and service plan last updated, 12/29/2025, did not include information about the use and periodic removal of the bedrails. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | - On 1/8/26, lead licensing agent advised Clinical Director to provide physician's scripts for the hospital beds utilized at the 117 West Metzger home by Individual #1 and Individual #4 (Which I believe is referenced as Individual #2 in description above). [Individual # corrected in violation from #2 to #4. (AES, HSLS on 1/29/26)]
- On 1/8/26 prior to the licensing exit interview, the Clinical Director provided a suitable physicians script for Individual #1 per lead licensing agent. Lead licensing agent advised Clinical Director to send him via email the corresponding hospital bed physicians' script for Individual #4. Lead licensing agent stated if he received the script before 5pm on 1/8/26, he would note the script accordingly and the pending citation for Code 207(5)(II) would be removed and both individuals files would be compliant.
- On 1/8/26 at 4:29 PM, Clinical Director sent requested script via email and at 4:46 PM lead licensing agent responded and confirmed receiving the script, which placed both individual's in compliance with Code 207(5)(ll). |
01/08/2026
| Implemented |