| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Service Plan, last updated 6/10/25, indicates that Individual #1 safely uses personal hygiene products and some household cleaning products. However, for all other types of poisonous substances, Individual #1 requires staff to assist in safely using them. This includes gases, oils, and solvents. In addition, Individual #1 may need some assistance in identifying some warning signs. "[Individual #1] has poor safety skills and needs assistance in this area [of identifying warning labels]." Individual #1's current assessment, completed on 8/5/25, informs that Individual #1 safely uses personal hygiene products and some household cleaning products safely. However, for all other types of poisonous substances, Individual #1 requires staff to assist in safely using them. This includes gases, oils, and solvents. At 10:33 AM on 9/18/25, unlocked and accessible in a cabinet located in the laundry room on the home's main floor were the following poisonous substances: a one-gallon jug of Super Clean Tough Task Cleaner-Degreaser; a 16-ounce Bernzomatic Portable Propane Tank with a warning label that read: "Danger---Extremely Flammable. Explosion Hazard. Contents Under Pressure. Carbon Monoxide Hazard"; five one-gallon bottles of Arocep Ultra Liquid Bleach; and one 32-fluid ounce bottle of Murphy's Concentrated Wood Cleaner. At 10:35 AM, unlocked and accessible underneath the kitchen sink were the following poisonous cleaners: two one-quart spray bottles of Zep Commercial Quick Clean Disinfectant. At 11:02 AM, unlocked and accessible underneath the sink of the full bathroom located on the home's second floor, were the following poisonous cleaners: a one-quart spray bottle of Zep Commercial Quick Clean Disinfectant; a one-gallon bottle of Arocep Ultra Liquid Bleach; and a 24-fluid ounce bottle of Clorox Toilet Bowl Cleaner. [Repeated Violation-10/8/24, et al] | Poisonous materials shall be kept locked or made inaccessible to individuals. | Individual #1 was reevaluated for poison safety and is able to safely use or avoid poisonous materials. Documentation was updated into the assessment on 10/2/2025. |
10/02/5025
| Implemented |
| 6400.77(b) | At 11:08 AM on 9/18/25, the home's first aid kit did not contain tape. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tape was replaced in the first aid kit on 9/19/2025. |
09/19/2025
| Implemented |
| 6400.106 | The Inspections and cleanings of the home's gas boiler system completed on 10/2/24, and then again on 9/10/25, were not conducted by a professional company. Rather, Agency Maintenance Personnel #1, who possesses a training certificate through American Trainco showing certification obtained on 8/11/14 to 8/12/14 in "Basic Electricity for the Non-Electrician," had completed the aforementioned boiler system inspections and cleanings. | 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.
| Landlord previously contacted 3D Facility Services and arranged for an annual furnace cleaning and inspection based on last years furnace installation date of September 2024. |
10/30/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's date-of-admission is 10/5/24. Their current assessment, completed on 8/5/25, did not address their progress over the last 365 days and current level of functioning in financial independence, as the corresponding field read: "Residential only, N/A." | 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.
| Individual's #1's assessment was updated on 10/2/2025 and identifies the individual's progress over the last 365 calendar days and her current level of functioning with financial independence. |
10/02/2025
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's date-of-admission is 10/5/24. Their current assessment, completed on 8/5/25, did not address their progress over the last 365 days and current level of functioning in managing personal property, as the corresponding field read: "Residential only, N/A." | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual's #1's assessment was updated on 10/2/2025 and identifies the individual's progress over the last 365 calendar days and her current level of functioning with personal property. |
10/02/2025
| Implemented |
| 6400.181(e)(14) | Individual #1's current assessment, completed on 8/5/25, did not address their knowledge of general water safety and ability to swim, as the corresponding field was left blank. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual's #1's assessment was updated on 10/2/2025 and identifies the individual's progress over the last 365 calendar days and her current level of functioning with water safety and the ability to swim. |
10/02/2025
| Implemented |
| 6400.216(a) | At 11:16 AM on 9/18/25, the door to the staff office located on the home's main level was not equipped with a lock. A purple binder, entitled, "North East: Go-To Book," containing Individual #1's current physical examination, completed medical appointments, Service Plan, Room and Board Contract, and demographic information, was unlocked and accessible in this upper-left cabinet of the desk in the staff office. | An individual's records shall be kept locked when unattended.
| Individual #1's record was placed on locked shelf within desk on 9/19/2025. |
09/19/2025
| Implemented |
| 6400.51(a)(3) | Direct Service Provider #2's date-of-hire is 3/25/25. Direct Service Provider #2 completed orientation training on 5/12/25. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Staff orientation was previously completed on 5/12/2025. |
05/12/2025
| Implemented |
| 6400.52(a)(1) | Direct Service Provider #2's date-of-hire is 3/25/25. Direct Service Provider #2 completed 20.0 hours of orientation training on 4/3/25, Direct Services Provider #2 did not work 20 hours on 4/3/25. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | New staff will be documenting training hours using "real time." Each training will be documented with a start time and an end time, allowing for accuracy in recording of training hours. |
10/10/2025
| Implemented |
| 6400.163(d) | Individual #1's current assessment, completed on 9/18/25, explains that Individual #1 does not take any medications but would need staff support in administration if Individual #1 did take any medications. At 11:08 AM on 9/18/25, atop a bookshelf next to Individual #1's bed within their bedroom, was an opened 32-count package of Extra Strength Tylenol (500 MG) dissolvable packets. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Extra Strength Tylenol has been placed in a locked cabinet. |
10/02/2025
| Implemented |