| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | Fire extinguishers are 1A rated, regulatory minimum is 2A. These have already been purchased and updated in the homes. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 2a rating Fire extinguishers were replaced on site |
04/07/2025
| Implemented |
| 6400.111(c) | Fire extinguishers are 1A rated, regulatory minimum is 2A. These have already been purchased and updated in the homes. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | 2a rating Fire Extinguisher were installed in the house during discovery |
04/07/2025
| Implemented |
| 6400.141(a) | Incomplete physical dated 3/27/2025. No prior physical found on file with respect to admission date of 5/16/2024. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual number 2 has a scheduled physical appointment with his PCP on 4/28/2025 |
04/28/2025
| Implemented |
| 6400.151(a) | The only physical found on file for staff person #2 was dated 12/17/2024. No physical predating hire date found. The staff person was hired on 2/8/2024. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff number 2 has a scheduled physical and TB date for 4/21/25 |
04/21/2025
| Implemented |
| 6400.165(g) | Psychotropic Med Review forms not found on file for every 90 days at minimum since 5/23/2024. | 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. | Individual number 2 has a scheduled appointment with his prescribing doctor for a 90 medication review on 5/2/2025 |
04/28/2025
| Implemented |