| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(f) | On 4/08/2026 at 10:35 AM, the only exit from the basement level of the home was the garage door. The fire drills completed 6/06/2025, 9/01/2025, 12/18/2025, and 3/15/2026 documented the individual used the basement exit to evacuate. | Alternate exit routes shall be used during fire drills. | On 4/10/2026 the program specialist reviewed fire drill procedures and evacuation practices. On 4/10/2026 The program specialist conducted a fire drill using the designated primary and secondary exits to ensure all individuals can safely and promptly evacuate the home. Any barriers to safe egress were addressed immediately, and exits were confirmed to be clear and accessible at all times. |
04/10/2026
| Implemented |
| 6400.214(a) | On 4/08/2025 at 10:47 AM, Individual #1's behavior support plan, completed 4/30/2025, was not present in the home. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | On 4/8/2026 the program specialist immediately obtained and placed a current copy of the individual's approved Behavior Support Plan in the home. |
04/08/2026
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 8/11/2025, states that the individual can be outside of direct supervision, when in his/her bedroom when he/she requests privacy, and he/she needs visual checks by staff every 15 minutes. Individual #1's individual support plan, last updated 3/12/2026, documents, " [The individual] is to have no unsupervised time at home···and is allowed privacy when using restroom at home." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 4/7/2026 the CEO reached out to the support coordinator again to update the individual #1 ISP which she did immediately, and I showed the license representative the next day. |
04/08/2026
| Implemented |