| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 5/29/2025 at 11:17AM, there were spray bottles of Windex and TB-Cide Quat Cleaner/Deodorizer/Disinfectant unlocked and accessible in the cabinet under the sink in the kitchen of the home. On 5/29/2025 at 11:21AM, there were spray bottles Windex, Clorox Bleach Foamer and TB-Cide Quat Cleaner/Deodorizer/Disinfectant unlocked and accessible in the cabinet under the sink in the bathroom on the first floor of the home. Individual #1's service plan, last updated, 5/13/2025, reads, [Individual #1] doesn't seek out poisonous substances, but they are kept locked in cupboards at all times as a safety precaution. [Individual #1] has no awareness of what constitutes a poison, nor does [Individual #1] have the ability to use cleaning supplies." | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 6/24/2025, a work order was sent to the Facility Manager to place locks on the cabinet under the sink in the kitchen and the sink in the bathroom on the first floor of the home. Poisonous materials will now be locked and made inaccessible to reflect Individual #1¿s ISP stating that ¿Individual #1 doesn¿t seek out poisonous substances, but they are kept locked in cupboards at all times as a safety precaution. Individual #1 has no awareness of what constitutes a poison, nor does Individual #1 have the ability to use cleaning supplies.¿ |
07/01/2025
| Implemented |
| 6400.83(c) | On 5/29/2025 at 11:36AM, there were four soiled bowls, six pieces of silverware, a large plastic serving spoon and a small pot in the sink in the kitchen in the basement of the home. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | A new goal will be implemented for the participant living in the practice apartment located in the basement of the home. The participant¿s goal will be participant will rinse and wash her dishes daily after each meal. Staff will check participant¿s dishes after each meal. If her dishes are not completed, staff will offer verbal reminders to complete her dishes. If participant refuses to wash dishes, staff will assist in washing dishes. Effective immediately, house staff will begin checking if the dishes are washed or if the participant needs assistance in completing the dishes after each meal. |
07/01/2025
| Implemented |
| 6400.101 | On 5/29/2025 at 11:46AM, there was a turn locking mechanism on the basement side and a key locking mechanism on the garage side of the door, between the basement and the garage of the home, posing an obstructed egress when the lock is engaged. There is no swing door inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 6/24/2025, a work order was sent to the Facility Manager to remove the current doorknob between the basement and garage of the home to a numbered keypad locking mechanism. The key locking mechanism where the turning lock mechanism is on the basement side and the keypad is on the garage side. The House Coordinator will educate the participant on the code, so they are able to independently lock and unlock the door. |
07/08/2025
| Implemented |
| 6400.32(r)(1) | On 5/29/2025 at 11:41AM, there was a turn locking mechanism on the inside with a pinhole locking mechanism on the outside of the door leading to the Individual #4's bedroom in the basement of the home. An entry mechanism to independently exercise the individual right to lock and unlock the door has not been provided to Individual #4. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | On 6/24/2025, a work order was sent to the Facility Manager to change the current doorknob to Individual #4¿s bedroom in the basement of the home to a numbered keypad locking mechanism so the Individual #4 is able to lock and unlock her door independently. The House Coordinator will educate Individual #4 on the code, so they are able to independently lock and unlock the door. |
07/08/2025
| Implemented |
| 6400.32(r)(3) | On 5/29/2025 at 11:30AM, there was a turn locking mechanism on the inside and a numbered keypad and a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. Staff interviews revealed that Individual #1 is not able to lock and unlock the door independently. On 5/29/2025 at 11:35AM, there was a turn locking mechanism on the inside and a numbered keypad and a keyed locking mechanism on the outside of the door leading to Individual #2's bedroom. Staff interviews revealed that Individual #2 is not able to lock and unlock the door independently. | Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. | An IDT (Interdisciplinary Team) Meeting will be held for Individual #1 and Individual #2 to discuss accommodations and educate each individual and legal guardian on the right to lock and unlock their door without assistance. Each IDT Team Meeting will be held by July 8, 2025. The Program Specialist will update Individual #1 and Individual #2¿s Annual Assessment to reflect the decision made at each IDT Meeting. The Program Specialist will request the ISP to be updated to reflect the decision made at each IDT Meeting. Annual Assessments and request for the ISP to be updated will be completed by July 16, 2025. If it is determined an Individual would benefit from accommodations to independently lock and unlock their door, a technology assessment will be completed to determine what lock best suites Individual #1 and Individual #2. |
07/16/2025
| Implemented |