| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The windowsill throughout the house, the kitchen cabinet door, and the Microwave need cleaning | Clean and sanitary conditions shall be maintained in the home. | Staff failed to ensure that the windowsills, kitchen cabinet and microwave were clean in the home.
On 3/11/26 the staff immediately cleaned the windowsills, kitchen cabinet and microwave. Staff also completed a site cleaning of the home. |
03/11/2026
| Implemented |
| 6400.73(a) | The stairwell leading upstairs from the 1st to the 2nd floor and the 2nd to the 3rd floor has no rail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The agency was overlooked that current handrail was too short in length.
On 3/11/26, maintenance team was notified to install handrails on 1st and 2nd floor. On 3/23/26 the handrails were installed. |
03/23/2026
| Implemented |
| 6400.76(a) | Bathroom seat loose, Bannister shaky | Furniture and equipment shall be nonhazardous, clean and sturdy. | The house manager failed to notify maintenance that the bathroom seat and bannister needed to be tightened.
On 3/11/26 the maintenance was notified to secure the bannister and the bathroom seat. On 3/23/26 the bannister and bathroom seat were tightened. |
03/23/2026
| Implemented |
| 6400.112(c) | The 7/31/25 fire drill does not have an evacuation time documented on the form. The area designated for the evacuation time information was left blank. The area designated for specific problems during evacuation was also left blank on the 7/31/25 form.
The 8/27/25 fire drill form does not indicate which exit was used at the time of the drill. | 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. | The house manager failed to ensure the fire drill record was fully completed.
On 3/11/26 the CEO arranged for a meeting to retrain admin staff on how to properly fill out a fire drill form. |
03/11/2026
| Implemented |
| 6400.112(d) | The evacuation time for the 6/17/25 fire drill was recorded as 2 minutes and 45 seconds, which exceeds the 2 and ½ minute requirement. There is no record of a repeat drill being conducted during the month of June. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The house manager failed to repeat the fire drill.
On 3/11/26 the CEO arranged for a meeting to retrain admin staff on the fire drill policy. |
03/11/2026
| Implemented |
| 6400.112(e) | During the time between 1/27/25 through 2/11/26, only one Sleep drill was conducted on 3/28/25. Sleep drills are required to be held during sleeping hours at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | The agency failed to have a standard tickler reminder system for overnight fire drills throughout the year.
On 3/11/26, the CEO developed a tickler system for the agency to conduct sleep drills every April and October. |
03/11/2026
| Implemented |
| 6400.141(b) | The 2/16/26 annual physical for individual #1 is not signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The staff failed to ensure the physician signature was on the form.
On 3/11/26 the physical form was sent to the doctors office to get a signature. |
03/11/2026
| Implemented |
| 6400.144 | Individual #1 had an ophthalmologist appointment on 7/17/25 where follow up was recommended in 6 to 8 weeks in the primary care clinic at Wills Eye. This follow up care was not scheduled/completed. | 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.
| The house manager failed to ensure medical appointment was scheduled as requested.
On 3/11/26, the Program Specialist scheduled a follow up appointment for an eye exam. |
03/11/2026
| Implemented |
| 6400.171 | Open cereal packages, sugar, snacks are not sealed in a Ziplock or storage container | Food shall be protected from contamination while being stored, prepared, transported and served.
| Direct support staff failed to ensure all opened food items were properly secured in a ziplock or storage container.
On 3/11/26 the house manager provided support staff with food containers. The support staff transferred all open food items into a ziplock or food container. |
03/11/2026
| Implemented |
| 6400.181(e)(10) | The Lifetime Medical History for individual #1 does not include the date of completion and is not attached to the annual assessment, so it is impossible to determine when it was updated/completed or if it was sent out to the team with the assessment as the assessment states. | The assessment must include the following information: A lifetime medical history. | The program specialist failed to ensure the Lifetime Medical History form was properly dated and sent out with the initial assessment.
On 3/11/26 the program specialist updated the date on the Lifetime Medical History. |
03/11/2026
| Implemented |
| 6400.163(h) | Lorazepam for individual #1 filled was filled on 1/2025 and expired 1/2026 | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Direct support staff failed to inform house manager Lorazepam was expired.
On 3/11/26, the house manager removed the Lorazepam from individual #1 medication box and discarded it. |
03/11/2026
| Implemented |