| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | At 12:40PM on 5/28/2026, the only telephone in the home with an outside line was stored in the locked staff office on the first floor of the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Upon receipt of the deficiency notice, the Program Manager purchased and installed a different telephone within the home to ensure that telephone service was readily accessible to both the individual and staff members at all times. The new telephone was installed in the living room on May 29, 2026, bringing the home into compliance with Regulation 6400.70 |
06/12/2026
| Implemented |
| 6400.77(c) | At 12:35PM on 5/28/2026, there was no first aid manual with the home's first aid kit. | A first aid manual shall be kept with the first aid kit. | Upon receipt of the deficiency notice, BrightPath Human Services conducted a thorough review of the home's first aid kit to verify whether the required First Aid Manual was present. During the review, the manual was located between larger bandage supplies within the first aid kit. As the First Aid Manual was present and readily available within the kit, the home was determined to be in compliance with Regulation 6400.77(c). This review was completed on May 28, 2026. |
06/12/2026
| Implemented |
| 6400.101 | At 12:24PM on 5/28/2026, there was a slide lock at the top and a turn locking mechanism on the basement side of the door with a keyed locking mechanism on the garage side of the door leading to the garage of the home posing obstructed egresses when engaged. There is no swing door inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Upon receipt of the deficiency notice, the slide lock located on the garage door in the basement was dismantled and removed. Additionally, the door knob has been turned around to place the locking mechanism on the garage side of the door to ensure the non-obstruction of an egress. This corrective action was completed on June 9, 2026, restoring unobstructed egress and bringing the home into compliance with Regulation 6400.101. |
06/12/2026
| Implemented |
| 6400.110(c) | At 12:20PM on 5/28/2026, the only smoke detector in the basement of the home was in the laundry room behind a closed door. There was no smoke alarm in a hallway or common area in the basement. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | Upon receipt of the deficiency notice, BrightPath Human Services ordered a new smoke detector from Home Depot that was compatible with the home's existing interconnected smoke detection system. Upon receipt, the smoke detector was installed in the basement hallway located between the main basement area and the laundry area. This corrective action was completed on June 8, 2026, bringing the home into compliance with Regulation 6400.110(c). |
06/12/2026
| Implemented |
| 6400.32(r)(1) | At 12:08PM on 5/28/2026, there was a thumb turn locking mechanism on the outside with a turn locking mechanism on the inside of the door leading to Individual #1's bedroom on the first floor of the home. Individual #1 has not been provided with a designated mechanism to independently lock and unlock the door. | 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. | Upon receipt of the deficiency notice, a new bedroom door knob was purchased and installed on Individual #1's bedroom door. The replacement door knob is a solid, non-locking door knob that does not contain a locking mechanism. Documentation was obtained confirming that Individual #1 and their guardian do not wish for the bedroom door to have a locking door knob. The door knob was replaced on June 11, 2026, bringing the home into compliance with Regulation 6400.32(r)(1). |
06/12/2026
| Implemented |
| 6400.32(r)(4) | At 12:08PM on 5/28/2026, there was a thumb turn locking mechanism on the outside with a turn locking mechanism on the inside of the door leading to Individual #1's bedroom on the first floor of the home. Staff did not have a designated mechanism to unlock the door in case of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Upon receipt of the deficiency notice, a new bedroom door knob was purchased and installed on Individual #1's bedroom door. The replacement door knob is a solid, non-locking door knob that does not contain a locking mechanism. Documentation was obtained confirming that Individual #1 and their guardian do not wish for the bedroom door to have a locking door knob. The door knob was replaced on June 11, 2026, bringing the home into compliance with Regulation 6400.32(r)(4). |
06/12/2026
| Implemented |