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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(r)(1) | On 8/27/2025 at 10:38AM, there was a turn locking mechanism on the inside and a pinhole locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been given a designated mechanism to lock and unlock the door independently. At 10:46AM, there was a turn locking mechanism on the inside and a keyed locking mechanism on the outside of the door leading to Individual #2's bedroom. Individual #2 has not been given a key to lock and unlock the door independently. | 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. | Immediate Corrective Actions Taken:
· Following inspection, staff were re-educated on the location and use of door lock mechanisms (pinhole unlocking device and key).
· Operations Manager confirmed that declination forms for both individuals were current, signed, and stored in the office compliance binder. -
Preventative Measures
1. Documentation:
o All declination forms will be reviewed annually, and the option will be presented to the Individuals to have or not have locked bedroom doors as per our current policy, the again at each ISP meeting to ensure continued choice.
2. Staff Training:
o Staff retraining on individual rights under §6400.32(r)(1), including the responsibility to ensure individuals have the option to lock/unlock their bedroom doors if they choose.
o Staff specifically trained on the location of bedroom door unlocking devices and keys.
3. Oversight:
o Program Specialist will review lock access during quarterly rights monitoring.
o Residential Supervisors will confirm during current monthly house meetings that staff know where keys/unlock devices are located and that declination forms are on file if individuals choose not to lock their bedroom and bathroom doors.
Responsible Staff
· Direct Support Staff/ Residential Supervisor: Ensure individuals are aware of their right to lock doors and assist with access if requested.
· Program Specialist: Confirm individuals' ongoing choices through quarterly rights reviews.
· Operations Manager: Verify staff awareness of key/device locations; Maintain declination forms; Monitor compliance and confirm individuals' ongoing choices by reviewing with each client their right to lock their bedroom door.
4. Doorknob will be replaced without locking mechanism |
09/26/2025
| Implemented |
| 6400.32(r)(5) | On 8/27/2025 at 10:38AM, there was a turn locking mechanism on the inside and a pinhole locking mechanism on the outside of the door leading to Individual #1's bedroom. Staff did not have a designated mechanism to unlock the bedroom door in case of an emergency. At 10:46AM, there was a turn locking mechanism on the inside and a keyed locking mechanism on the outside of the door leading to Individual #2's bedroom. Staff did not have a key to lock and unlock the bedroom door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Immediate Corrective Actions Taken:
1. Keys for all locking bedroom doors, including Individual #1's, were immediately confirmed, labeled, and tested to ensure proper function.
2. Staff were informed and shown the location of the key for Individual #1's bedroom on the same day as the inspection.
3. The keyed lock was tested in front of staff to demonstrate access and ensure no barriers to emergency entry exist.
Preventative Measures:
1. Key Inventory & Labeling: All keys for bedroom doors have been inventoried, labeled, and placed in a designated secure but accessible staff area.
2. Staff Training: All staff will receive training on the regulatory requirement that staff must have immediate access to unlock bedroom doors in case of emergency. Training will include practical demonstrations of key use.
3. Secondary keys have been placed on the car key ring in addition to the copy on the key ring for the home..
4. Ongoing Monitoring: Residential Supervisor will conduct checks during their weekly walk through to ensure keys are present, labeled, and staff can identify and use them. Results will be documented. |
10/01/2025
| Implemented |
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