| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(a) | The home only has one wheelchair accessible entrance/exit. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Another new entrance/exit Wheelchair accessible has been constructed. |
04/29/2025
| Implemented |
| 6400.104 | The letter to the Fire Department does not contain information pertinent to rendering assistance to the Individual who resides there who is non-ambulatory. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The letter to Fire Department has been revised and all appropriated information has been document |
05/01/2025
| Implemented |
| 6400.112(f) | All completed fire drills utilized the same exit as wheelchair accessibility is only available through the back of the home. | Alternate exit routes shall be used during fire drills. | since the new entrance/exit Wheelchair accessible has been constructed, an alternate exit route shall be used during fire drills |
04/30/2025
| Implemented |
| 6400.113(a) | Fire Safety Training is dated 1/27/25, however there is no previous fire safety training on file for individual #2 | 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. | The individual #2 fire drill was misplaced and has been found. |
04/30/2025
| Implemented |
| 6400.217 | There were no signed consents on file for individual #2 | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| A signed consent has been completed. |
04/30/2025
| Implemented |
| 6400.32(d) | The Agency completed an excessive amount of sleep drills causing frequent interruptions to the Individual's sleep. Sleep drills were completed on 3/12/24, 6/10/24, 9/15/24, 11/15/24, and 2/19/25. | An individual shall be treated with dignity and respect. | The individual sleep drill has been corrected. |
04/30/2025
| Implemented |
| 6400.34(a) | Individual #2 does not have a signed individual rights statement on record. | 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. | Individual #2 rights statements has been signed. |
04/30/2025
| Implemented |
| 6400.181(f) | There is no documentation at individual #2's 4/4/24 annual assessment was sent to the team 30 days prior to their ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual #2 annual assessment has been rectified. |
04/30/2025
| Implemented |