| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.61(a) | A home serving an individual with a physical disability shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. Individual #1 requires a rolling walker or rollator to ambulate at the present time. The home has a ramp leading to a side door which enters the home into a storage area. Between the storage room/area, there is a lip or threshold in the transition area from the storage area to the main living area that the LSP and LSS stated that the individual trips over, so the individual refuses to use that ramp and climbs the stairs to the front porch and enters through a different door than the one served by the ramp. The individual has a recent documented history of falls resulting in injury, and needs to have safe accommodations to enter, exit and move about the home that doesn't involve using stairs with a walker or traveling over floor thresholds or transitions that could be a tripping hazard. | A home serving an individual with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Providers landlord is installing floor elevation between the two entryways of the home. |
10/01/2025
| Implemented |
| 6500.64(b) | There may not be evidence of infestation of insects or rodents in the home. At the time of the inspection, there were many flies observed in the home, as well as a sticky fly tape strip hanging from the bathroom ceiling that was covered with dozens of dead flies, indicating a possible infestation. | There may not be evidence of infestation of insects or rodents in the home. | All sticky fly tape strips have been removed from the home. The presence of the flies no longer existed at the time of most recent walkthrough conducted. |
09/02/2025
| Implemented |
| 6500.65 | Living areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The bathroom does not have an operable window or a source of mechanical ventilation. | Living areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. | Provider's landlord is installing a vent into the bathroom without a window. |
10/01/2025
| Implemented |
| 6500.66 | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. The exit at the rear of home, located from the storage room to the exterior of the home, does not have an operable light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents. | Provider's landlord is installing a light fixture at the exit of the rear of the home. |
09/19/2025
| Implemented |
| 6500.67 | -- Floors, walls, ceilings and other surfaces shall be free of hazards. The basement level of the home was filled with water at the time of the inspection. The basement had a dirt floor and there was no sump pump. This inspector was not able to step from the bottom step to the basement floor as the water appeared to be at least ankle deep. The life sharing provider said it was a new issue, but it did not appear to be a new issue as the furnace that had been installed last year was placed up on blocks, and there have been no recent storms or rainfall. There were some boards or planks laying on the floor to be used as walkways through the water. It did not appear that any attempts had been or were being made to eradicate the water in the basement. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Provider's landlord has ordered a sump pump replacement for the basement to be installed. |
10/01/2025
| Implemented |
| 6500.73 | An interior stairway exceeding two steps shall have a well-secured handrail.
The handrail on the staircase leading from the first floor to the second floor did not cover the entire expanse of the staircase. The handrail did not start until the fourth stair riser of the staircase.
The handrail on the staircase leading from the second floor to the attic was not secured to the wall and was laying on the side of the staircase. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | The handrail in the attic has been reattached. The landlord will install handrails where the gaps exist between the first and second floor. |
10/10/2025
| Implemented |
| 6500.101 | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. The door to the basement stairs was obstructed by a padlock at the top of the stairs on the first-floor side of the door. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The padlock was removed from the basement door. |
09/02/2025
| Implemented |
| 6500.107(a) | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
At the time of the inspection, the smoke detector for the basement was located at the top of the basement stairs, which is a floor above the basement. The smoke detector for the attic was located at the bottom of the attic stairs, which is a floor below the attic. | A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic. | Provider relocated the smoke detector in the basement to the bottom of the basement stairs. Providers relocated the smoke detector to the top of the stairs of the attic. |
09/02/2025
| Implemented |
| 6500.108(a) | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. At the time of the inspection, the fire extinguisher for the basement was located at the top of the basement stairs, which is a floor above the basement. The fire extinguisher for the attic was located at the bottom of the attic stairs, which is a floor below the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The basement fire extinguisher was moved to the bottom of the staircase. The attic fire extinguisher was moved to the top of the attic staircase. |
09/02/2025
| Implemented |
| 6500.109(a) | A fire drill shall be held at least every three months until all individuals are able to evacuate within 2 and ½ minutes, without family assistance, or with family assistance if the individual is never alone in the home. Three fire drills have occurred since the individual moved into the home, one every six months. The fire drill held on 12/03/2024 recorded an evacuation time of 2 minutes and 53 seconds, over the 2 and ½ minute evacuation time limit, and indicates that the individual is not able to evacuate within 2 and ½ minutes and requires the home to conduct drills every three months. The next fire drill occurred on 6/03/2025, six months after the previous drill. | A fire drill shall be held at least every 3 months, until all individuals demonstrate the ability to evacuate within 2 1/2 minutes, or within the period of time specified in writing within the past year by a fire safety expert, without family assistance, or with family assistance if the individual is never alone in the home. The fire safety expert may not be a family member or employee of the agency. | Additional fire drills every 3 months will be conducted by the provider if the individual is unable to maintain evacuation within 2 1/2 minutes as required and obtain a fire safety letter. |
09/02/2025
| Implemented |
| 6500.109(e) | A fire drill shall be held during sleeping hours at least once every 12 months. The home has conducted three fire drills since Individual #1 has moved into the home; on 6/03/2024 at 6:30 PM, 12/03/2024 at 9:00 PM and 6/03/2025 at 5:00 PM. None of those drills occurred sleeping hours. | A fire drill shall be held during sleeping hours at least every 12 months. | Provider will conduct overnight drills after 9pm and not the same time frames moving forward. |
09/02/2025
| Implemented |
| 6500.122(a) | An individual 18 years of age and older shall have a dental examination performed by a licensed dentist annually. Individual #1 had a dental examination and cleaning on 4/01/2024, then not again until 6/16/2025 which exceeds the annual requirement. | An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Provider will ensure attendance to all follow up appointments arranged by a medical physician and/or dentist as recommended. Individual had an appointment on 7/29/2024 with Dr. Owen (Sayre Dental) subsequent to 4/1/24 for restoration of the filling documented. |
09/02/2025
| Implemented |
| 6500.124 | Health services shall be provided. Individual #1 had a dental examination and cleaning on 4/01/2024. At that appointment, the dentist had recommended a six-month follow up for an examination and cleaning. The six-month follow up appointment was scheduled for 10/30/2024 but that appointment was not kept. The individual's next examination and cleaning was completed on 6/16/2025, eight months after the 6 months recall appointment was to have occurred, and 14 months after the examination and cleaning on 4/01/2024. | 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. | Provider will ensure that individual is provided annual dental examinations within a 12 month period. |
09/02/2025
| Implemented |
| 6500.69(c) | When the indoor temperature in individual bedrooms or life sharing areas exceeds 85° F, mechanical ventilation such as fans shall be used. The temperature on the first floor, where the individual's bedroom is located, was 89.7° F at the time of the inspection and it did not appear that mechanical ventilation was in use. | When the indoor temperature in individual bedrooms or life sharing areas exceeds 85°F, mechanical ventilation such as fans shall be used. | Provider turned the floor fans as well as ceiling fans on. |
09/02/2025
| Implemented |
| 6500.135(g) | If a medication is prescribed to treat the symptoms of a psychiatric illness, there shall be a review with documentation by a licensed physician at least every three months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness and reviews with a licensed physician did not occur every three months as required. Documentation in the individual's record showed that medication reviews occurred on 9/25/2024 and 12/31/2024, then not again until 6/12/2025. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Provider will ensure that the individual has psychiatric medication reviews every three months or more as needed/recommended by physician. |
09/02/2025
| Implemented |
| 6500.136(b) | The name and initials of the person administering medications shall be recorded at the time the medication is administered. The electronic medication administration record (MAR) was not signed on 8/01/2025, 8/03/2025 and 8/10/2025 for the 8:00 PM administrations for the medications clonazepam, Eliquis, Tegretol, topiramate and Zyprexa. It appeared that the medications were administered and there was no entry in the MAR to indicate that the person was away from the home or other reason to not sign the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Provider will be retrained on medication administration to ensure understanding of documenting in the MAR and what clerical errors mean. |
09/02/2025
| Implemented |