| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 1/29/2026 at 10:35 AM, the following poisons were found unlocked under the kitchen sink: three bottles of Lysol Disinfectant Spray, one bottle of Clorox Bleach Spray, and 1 container of cleaning wipes. These items all have instructions to contact poison control if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 01/28/2026 at time of inspection Community Homes, Director Region # 9 locked poisonous materials. |
01/28/2026
| Not Implemented |
| 6400.181(e)(1) | Individual #1's assessment completed on 10/13/2025 did not include function strengths, needs and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 02/23/2026, Assessment for Individual updated to include functional strengths, needs and preferences. Updated Assessment emailed to Supports Coordinator. |
02/23/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1 participated in training to encompass the implementation of the individual plan for the individuals they work directly with on 2/27/2025. The record for this training did not include the length of 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. | Temporary staff #1 will not be utilized by Lifesteps until trainings completed and documented.
02/03/2026, Temporary Agency was notified via email by Administrative Assistant, Program Administration that any Temporary Staff not in compliance with required annual trainings by 02/17/2026 will not be utilized until compliance is documented. |
02/03/2026
| Not Implemented |
| 6400.52(c)(5) | Direct Service Worker #1 did not participate in training to encompass the safe and appropriate use of behavior supports for the individuals they work directly with during the 7/1/2024 through 6/30/2025 annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | 10/22/2025 Temporary Staff #1 was trained on ODP Behavior Support and Crisis Intervention Plan.
02/02/2026 Administrative Assistant, Program Administration audited all Temporary Staff trainings; identified Temporary Staff were suspended by the Senior Director until they were brought into compliance. |
10/22/2025
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. Individual #1 had psychotropic medication reviews completed by a licensed physician on 5/28/2025 and then again on 11/28/2025. This exceeds the at least every 3 months requirement. | 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. | 02/27/2026 Obtained documentation from MYUPMC account that demonstrates psychotropic medication review completed 08/19/2025 and 11/11/2025. |
02/27/2026
| Implemented |