| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | Only one sleep hour drill between the hours of 11pm to 7am was conducted since the last inspection date that occurred on 10/25/24:
-11/19/24: 7-3 shift
-12/14/24: 3-11 shift
-1/29/25: 3-11 shift
-1/30/25: 7-3 shift
-2/25/25: 3-11 shift
-3/19/25: 7-3 shift
-4/24/25: 3-11 shift
-5/16/25: 3-11 shift
-6/25/25: 3-11 shift
-7/30/25: 7-3 shift
-8/28/25: 3-11 shift
-9/13/25: shift listed as 11:00pm, drill time listed as 11:10pm | A fire drill shall be held during sleeping hours at least every 6 months. | 1. Corrective Action Taken:
The provider conducted a sleep-hour fire drill on 11/09/2025 to ensure compliance with the regulation. Staff and individual(s) participated and demonstrated appropriate evacuation procedures. Documentation of this drill has been completed and filed.
2. Person Responsible:
Program Manager
3. Completion Date:11/10/2025 |
11/10/2025
| Implemented |
| 6400.113(a) | Individual #1 received fire safety training upon admission on 2/26/24 and then again on 5/2/25. The timeframe between these two training dates exceeds the annual requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 1. Corrective Action Taken:
Individual #1 was re-instructed in fire safety, evacuation procedures on 05/02/2025. Documentation of the training has been completed and placed in the individual's record. The Program Director has made a schedule to ensure compliance with yearly required training moving forward.
2. Person Responsible:
Program Director/ Fire Safety Specialist
3. Completion Date:
11/10/2025 |
11/10/2025
| Implemented |
| 6400.34(a) | The consumer bill of rights form which reviews individual rights for individual #1 was reviewed with and signed by the individual's legal guardian upon admission on 2/26/24. This form was not reviewed and signed annually as required by regulation. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Consumer Bill of Rights was reviewed with Individual #1 and their legal guardian on 02/15/2025. Documentation has been placed in the individual's record.
Person Responsible:
Program Director
3. Completion Date:
11/10/25 |
11/10/2025
| Implemented |