| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The following areas of the home are in need of repair:
-Both closet doors were off of the tracks, and the knobs to open them were loose and the hardware being used was the wrong size.
-The dresser in individual #1's bedroom was broken and in need of repair or replacement.
-The stopper in the bathroom sink was missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program specialist will do rounting weekly check on house closets and Apartment complex notified for repairs. |
03/14/2025
| Implemented |
| 6400.72(b) | The window in Individual #1's bedroom would open, but it would not hold itself up if not being supported. The window needs to be repaired. | Screens, windows and doors shall be in good repair. | Program specialist will check all windows to make sure they are in good order |
03/14/2025
| Implemented |
| 6400.110(b) | The only functional smoke detector in the home was in the living room area, however there needs to be an operable smoke detector within 15 feet of the individual's bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | There are two smoke detectors in the house both 15 ft away from each bedroom. One was missing the battery . The battery was replaced. |
03/07/2025
| Implemented |
| 6400.111(c) | There was no fire extinguisher in the kitchen at the time of inspection. | 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). | The fire extinguisher was present but kept in the storage room. Program specialist will ensure fire extinguisher will be kept unlock in the kitchen . The fire extinguisher was brought back to the kitchen. |
03/07/2025
| Implemented |
| 6400.111(e) | The fire extinguisher in the home was locked in the closet and inaccessible in the event of an emergency. | A fire extinguisher shall be accessible to staff persons and individuals. | The fire extinguisher was present but kept in the storage room. Program specialist will ensure fire extinguisher will be kept unlock in the kitchen . The fire extinguisher was brought back to the kitchen. |
03/07/2025
| Implemented |
| 6400.141(a) | An Individual should have a physical completed annually. Individual #1 had a physical completed 1/26/24 and 3/5/25 which exceeds the established 15-day grace period. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The program Specialist will look over each annual physical appointment and make appointment six months ahead of time and will check every month on the availability and also document if client refused or appointment cancelled. |
03/07/2025
| Implemented |
| 6400.141(c)(10) | Individual 1's physical must indicate if the person is free from communicable diseases to determine if specific precautions are necessary. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Staff did complete his physical but Physical did not indicate whether staff #1 is free of communicable diseases. Staff #1 took back the physical to be completed and was completed and returned free of communicable disease.. |
03/10/2025
| Implemented |
| 6400.141(c)(14) | Individual 1's physical must include information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physician did not complete that section during the annual physical but was completed on 03/10/25 |
03/10/2025
| Implemented |
| 6400.52(c)(4) | Staff Member #1 did not complete a training on recognizing and reporting incidents in the 2023/2024 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The annual training on recognizing and reporting incidents was completed in 2025. |
03/14/2025
| Implemented |
| 6400.166(a)(11) | The MAR for Individual #1 did not contain any details about the medications, including their purpose or effects. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Details about medication is kept on site to provide literature about medication taken . |
03/08/2025
| Implemented |
| 6400.195(a) | The sharp knives in the home were locked in the kitchen area. This is considered a restrictive procedure and a restrictive procedure protocol needs to be followed in order to keep them inaccessible. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | sharp Knives was kept inside a case unlocked and eating knives inside the draw . Staff will ensure all knives are kept inside the regular kictchen draw and unlocked. They were removed and placed inside the kitchen draw. |
03/07/2025
| Implemented |