| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | At the time of the inspection, the left kitchen cabinet knob located under the sink was missing. The kitchen cabinet above the microwave and the cabinet about the stove on the left each had a loose knob. When the Licensing Representative pointed out the loose knobs by spinning them and the metal decorative pieces attached to the knobs. Agency staff tightened the 2 knobs during the inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | Knobs were replaced and tightened. Attachment #7 |
02/19/2026
| Implemented |
| 6400.67(b) | At the time of the inspection, approximately ¾ of the black nonskid strip of tape located on the first step/landing leading down to the basement was pulled up/off of the step posing a tripping hazard. When the Licensing Representative pointed out the pulled up nonskid tape, agency staff removed the entire piece of tape from the step. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Black nonskid strip was replaced and is secure. Attachment #8 |
02/19/2026
| Implemented |
| 6400.77(c) | At the time of the inspection, the first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | Manual was placed in the first aid kit. |
02/19/2026
| Implemented |
| 6400.112(c) | The fire drill conducted on 8/29/25 at 9:55 am did not include the time required to exit the home on the agency form. All the fire drills reviewed by the Licensing Representative (LR) indicated the time required to evacuate in specific minutes and seconds that it took to evacuate, and the 8/29/25 fire drill was indicated only as 9:57am. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Specialist will review fire drills after they are completed on a monthly basis to ensure the necessary items are answered as required by the regulations. |
02/19/2026
| Implemented |
| 6400.142(d) | Individual #1 had a dental appointment on 2/14/25, and the form did not indicate/document if that teeth cleanings or checking gums and dentures were performed for Individual #1 as the agencies form was left blank for presenting problems, impression, and treatment. | The dental examination shall include teeth cleaning or checking gums and dentures. | Program Specialist will review appointment forms where the doctors document what was done at the appointment. If the appointment form does not have the necessary information needed, the Program Specialist will call the providers office to get better documentation of what was completed at the appointment. |
02/19/2026
| Implemented |
| 6400.181(a) | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home. The initial assessment in Individual #1's file did not have a date on it. The only date on the assessment was on the first page of the assessment for the admission date, 2/10/25, for Individual #1. The back page and block of the assessment where the agency has the Individual and Program Specialist date the assessment was left blank. Therefore, there is no way to determine when the assessment was completed. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program Specialists will sign and date the annual assessments after review and completion. Director of IDD Residential will review assessments prior to being uploaded into the individual's file. |
02/19/2026
| Implemented |
| 6400.181(d) | Individual #1's assessment was not signed or dated by the Program specialist, Staff #2. | The program specialist shall sign and date the assessment. | Program Specialists will sign and date the annual assessments after review and completion. Director of IDD Residential will review assessments prior to being uploaded into the individual's file. |
02/19/2026
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment, which was not dated, under financial independence reported Threshold is Individual #1's rep-payee and is fine with the way her finances continue to be handled. Individual #1's Individual Support Plan (ISP) states that Individual #1 does not manage her own money but makes small purchases with assistance. The agency did not assess Individual #1 in their financial management/independence. | 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.
| Program Specialist updated the financial section in her Annual Assessment to reflect a more accurate description to her financial management/independence. See attachment #9 |
01/16/2026
| Implemented |
| 6400.44(c)(2) | A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.
Staff #1 does not meet the qualifications to be a Program specialist as Staff #1's resume only documented that they had only 1 year, 9 months and 18 days of experience working directly with individuals with an intellectual disability or autism. | A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism. | Program Specialist resume shows having a bachelor's degree in psychology and 29 months of work experience. See attachment #10
NOTE: After speaking with Mr. Krenitsky from Threshold, it was decided the staff member did not actually have the required experience upon hire but does now since being under the supervision of Threshold. -KS |
02/19/2026
| Implemented |
| 6400.165(a) | A prescription medication shall be prescribed in writing by an authorized prescriber. According to the Regulatory Compliance Guide (RCG) prescription medications include over the counter (OTC) medications. At the time of the inspection, located in a plastic Ziploc bag with Individual #1's medications was a bottle of Visine Red eye comfort eye drops that was approximately ¾ of the way full. The Visine Red Eye comfort eye drops were not prescribed/ordered to Individual #1. The agency would want to ensure that Individual #1 can take the medication and that they're not contradictive of their other medications. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Visine Red Eye comfort eye drops that were not prescribed by an authorized prescriber was removed. |
02/19/2026
| Implemented |