| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | They were spray bottles stored in the basement with cleaning solution, not in the original container | Poisonous materials shall be stored in their original, labeled containers. | All new cleaning supplies were purchased and put in the home on 2/15/26. Supplies are clearly labeled, and all unlabeled items are removed from the homes (Attachment #9). Verified on 3/23/26 |
03/23/2026
| Implemented |
| 6400.104 | There is no record that the notification to the fire department was updated and sent out when individual #3 was admitted to the program on 9/22/25. The last notification letter in the record is dated 6/17/24. | 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.
| On 2/26/2026, a new fire letter was sent to the local fire department to ensure they had an accurate letter (Attachment #12). |
03/06/2026
| Implemented |
| 6400.112(e) | Sleep fire drills were held on 2/22/25 and 11/8/25. Sleep fire drills shall be held at least every six months, and these dates are greater than six months apart. | A fire drill shall be held during sleeping hours at least every 6 months. | On 3/3/2026, a memo was sent out to house supervisors and administrators that all houses will follow an asleep drill for April and October each year (attachment #1). On 3/1/2026, Fire Drill Forms were not implemented as Google Sheets, in which administrators are able to see the Fire Drill Form immediately after submission to review (Attachment #2). |
03/06/2026
| Implemented |
| 6400.141(c)(13) | The 02/02/26 Physical for Individual #3 does not address contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | The physical form was returned to her physician's office on 2/16/26 for correction. (Attachment # 5) House managers received training on how to ensure physical forms are completely filled out on 2/18/26. (Attachment #13). |
03/06/2026
| Implemented |
| 6400.165(g) | Individual #3 was admitted on 09/22/25. The individual is prescribed medications to treat psychiatric illness, which requires review every 3 months. The first review on record for the licensing period was completed on 02/06/26. No other records were available prior to this date. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Family reports they would like to continue to schedule and attend appointments with Individual #3. The family received training on ODP regulations, as they did not understand why documentation was required. |
03/06/2026
| Implemented |