| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.105 | At 11:29 AM on 1/28/26, there was a piece of significantly frayed carpeting, measuring approximately three feet by one and one-half feet, underneath the gas furnace located in the home's basement that posed as combustible material. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The carpeting that was frayed was removed by the providers' maintenance technician. Evidence of the removed carpeting is included with this plan of correction as Attachment #1. |
04/03/2026
| Implemented |
| 6400.106 | The furnace in the home was inspected and cleaned by a professional furnace cleaning company on 11/12/24, and then again on 12/22/25. This exceeds the annual requirement. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Provider reviewed current practices regarding tracking and scheduling of furnace inspection and cleaning and implemented a tracking system to allow for timely inspections and cleanings in accordance with 6400.106. |
04/03/2026
| Implemented |
| 6400.141(c)(7) | Individual #1 had a gynecological examination performed on 06/08/22, with documentation from a licensed physician recommending gynecological examinations every three years, and no additional documentation of an examination completed since was provided to measure compliance. This exceeds the recommendation by the physician. [Repeat violation 03/10/25 et al] | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Provider immediately scheduled an updated gynecological exam for Individual #1. That appointment occurred on 2/25/2026. A copy of the visit form is included with this plan of correction as Attachment #3
An audit of all physical exams was conducted to ensure compliance with regulatory requirements for all affected individuals. This was completed by the Nurse, IDD Administrative Coordinator and Group Home Supervisor by 2/28/2026 |
04/03/2026
| Implemented |
| 6400.141(c)(8) | Individual #1 is age 69. Individual #1's current physical examination, completed on 5/22/25, included physician recommendations for having a mammogram conducted annually. However, Individual #1 had mammograms completed on 1/10/24, and then again on 3/12/25. This exceeds the annual requirement. | 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. | Provider immediately scheduled an updated mammogram for Individual #1. That appointment occurred on 2/25/2026. A copy of the visit form is included with this plan of correction as Attachment #3
Provider conducted an audit of all individuals requiring a mammogram to ensure full compliance in accordance with 6400.141(c-8). This audit was completed by 2/28/2026. |
04/03/2026
| Implemented |
| 6400.181(e)(1) | Individual #1's current assessment, completed on 5/2/25, did not include their needs and preferences, as there are neither corresponding fields, nor information addressing this content throughout the entire document. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1s assessment was reviewed by the team to ensure all areas of required information in accordance with 6400.181(e-1) were referenced. Program Specialist updated the plan to include the needs and preferences of the individual. The Assessment was updated on 3/6/2026. The assessment is included with this plan of correction as Attachment #4. |
04/03/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's current assessment, completed on 5/22/25, did not include recommendations for specific areas of training, programming, and services to promote skill growth. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1s assessment was reviewed by the team to ensure all areas of required information in accordance with 6400.181(e-12) were referenced. Program Specialist updated the plan to include the needs and preferences of the individual. The Assessment was updated on 3/6/2026. The assessment is included with this plan of correction as Attachment #4 |
04/03/2026
| Implemented |
| 6400.214(b) | At 11:19 AM on 1/28/26, neither hard nor electronic copies of the following most current records were being kept at the home for Individual #1: an assessment; and an applicable psychological evaluation | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Both documents were placed in the home on 3/9/2026. These documents have also been provided as a part of this plan of correction as Attachments#4 and #5.
A comprehensive assessment and psychological evaluation for the individual will be obtained from a qualified licensed professional. The completed evaluation will be placed in the individual's record in the home to ensure accessibility for staff and regulatory review. A full audit of all individual records within the home will be conducted to verify that each individual has a current assessment and psychological evaluation on file as required. |
04/03/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1's date-of-hire is 9/29/25. Direct Service Worker #1 completed orientation training on 10/10/25 in the area of job-related knowledge and skills regarding individual-specific reviews of behavior support plans and service plans. However, this in-person training neither documented the trainer who had conducted the session, nor its course length. | 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 has reviewed the identified training sign-in sheet and updated it to include the trainer's full name and the total length of the training session. The training sign in sheets are included in this plan of correction as Attachment #9 and Attachment #10. |
04/02/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness, and there was a review by a licensed physician on 04/09/25, and then again on 09/24/25. This exceeds the every 3-month requirement. Additionally, no other documentation of appointments was provided for review and measuring compliance. This exceeds the every 3-month requirement. [Repeat violation 03/04/25, 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. | Provider scheduled a 90 day medication review to occur on 4/22/2026. Provider will ensure all 90 day medication reviews are scheduled and attended within the timeframes specified in 6400.165(g). |
04/22/2026
| Implemented |
| 6400.213(1)(i) | Individual #1's date-of-admission is 4/12/14. However, neither Individual #1's demographics page, nor their content of records included admission date. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Action was taken to add the date of admission to Individual #1's records. Records were updated to include the date of admission. The date of admission was 4/12/2014 and has been added to the face sheet which is included with this plan of correction as Attachment #8.
Provider immediately reviewed all other service recipients documentation to ensure the date of admission is noted for each individual person respectively. This was completed by 4/1/2026. |
04/01/2026
| Implemented |