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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Service Plan, last updated 1/22/26, states that, "Poisonous substances, such as cleaning products, are kept out of [Individual #1's] reach" and that, "[Individual #1] requires visual supervision to maintain [their] safety at all times." In addition, Individual #1's current assessment, completed on 6/9/25, provided a score of "1," meaning that Individual #1 requires physical manipulation and assistance throughout the entire process to avoid and use poisons and that poisons are to be locked. At 12:37 PM on 2/2/26, all of the home's cleaners were stored in a closet located in the living room with a door equipped with a key lock. However, the corresponding key to this closet's door lock was hung on the wall approximately two inches to the right of this closet, affording accessibility to these poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On February 3, 2026, the COO relocated the key hook to a concealed area inside the medication cabinet to ensure secure storage and compliance with regulatory standards. |
02/03/2026
| Implemented |
| 6400.67(b) | At 12:44 PM on 2/2/26, the sewer drain located in the center of the home's basement floor did not have a grate cover, exposing a circular hole measuring four inches in diameter that posed a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On February 9, 2026, the Maintenance Director installed a replacement drain cover to correct the identified deficiency. |
02/09/2026
| Implemented |
| 6400.112(f) | According to the written fire drill record submitted from 5/2/25 to 1/8/26, the home's two exit routes were not alternated, as the front door was utilized on all nine drills conducted. | Alternate exit routes shall be used during fire drills. | On February 10, 2026, at 4:15 p.m., an unannounced fire drill was conducted under normal staffing conditions by the Program Specialist. The alternate exit was utilized as the designated emergency exit. The drill was completed successfully. |
02/10/2026
| Implemented |
| 6400.171 | At 12:35 PM on 2/2/26, inside the oven were the following foods unprotected from contamination: an opened package of raw chicken wings. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Upon discovery, all food items were immediately transferred to appropriate storage containers, properly labeled with dates, and stored in accordance with food safety standards. |
02/06/2026
| Implemented |
| 6400.32(r)(4) | At 12:41 PM on 2/2/26, Individual #1's bedroom door was equipped with privacy lock having a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | On February 2, 2026, maintenance personnel replaced the bedroom door locking mechanism to reflect the individual's selected doorknob style in accordance with their preference. |
02/02/2026
| Implemented |
| 6400.182(c) | Individual #1's Service Plan, last updated 1/22/26, contained the following discrepancies between their initial and current assessment, completed on 6/9/25, in the following health and safety skill domains: regarding fire evacuation, Individual #1's Service Plan, last updated 1/22/26, explained that, "[Individual #1] needs full physical assistance (staff pushing [their] wheelchair) for evacuating a building during a fire. If [Individual #1] is sleeping, [Individual #1] needs to be physically picked up and put into [their] chair and then full physical assistance [provided] [for] [Individual #1] finding [their] way to the designated meeting area." In contrast, Individual #1's assessment, completed on 6/9/25, indicated, "Yes," denoting that Individual #1 can leave the building safely when the alarm sounds (within 2.5 minutes); and regarding home supervision, Individual #1's Service Plan, last updated 1/22/26, informed that Individual #1 requires 24-hour supervision and that, "[Individual #1] is always provided visual supervision and full physical assistance to navigate···[their] home. [Individual #1's] wheelchair is used for all aspects of mobility" and that, "[Individual #1] can be left alone in a room for short periods of time within visual and auditory supervision once the area has been determined to be free of small objects and other hazards that [Individual #1] can ingest." However, Individual #1's assessment, completed on 6/9/25 indicated only that Individual #1 is required to be within hearing distance of staff at all times during awake and sleeping hours. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On February 11, 2026, the Program Specialist updated the individual's assessment to accurately reflect the appropriate level of care and supervision. The revised assessment was redistributed to all relevant team members. |
02/11/2026
| Implemented |
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