| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 10/22/2025 at 11:58 AM, the basement's only sink was enveloped entirely with a mixture of brown debris, dust, dirt, and cobwebs. | Clean and sanitary conditions shall be maintained in the home. | Basement is kept locked and sink is not used at any time. Sink is not necessary and will be removed by maintenance. |
11/06/2025
| Not Implemented |
| 6400.66 | On 10/22/2025 at 12:02 PM, the basement's only exterior door opened to a vestibule containing seven steps to a set of Bilco doors. This vestibule did not contain a light source. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Provider has contacted electrician to resolve the issue and install light fixture to basement vestibule. |
12/31/2025
| Implemented |
| 6400.67(b) | On 10/22/2025 at 11:59 AM, the sump pump unit, located in the corner of the basement next to the sink, did not have a cover, thus, exposing a square hole in the floor that measured two feet in length, by two feet in width, by two feet in depth, and posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | To ensure floors, walls, and other surfaces are free from hazards, cover will be placed on sump pump unit as soon as possible by plumbing contractor. |
12/31/2025
| Implemented |
| 6400.72(a) | On 10/22/2025 at 11:46 AM, the window located above the kitchen sink did not have a screen. At 11:52 AM, the window in Individual #1's bedroom facing the left side of the home was fitted with an accordion screen that was smaller than the window frame, leaving a ten-inch gap along the top of the window opening. At 12:11 PM, the window in the living room facing the right side of the home was fitted with an accordion screen that was smaller than the window frame, leaving a ten-inch gap along the top of the window opening. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Provider will have contractor install properly fitted screens to all necessary windows/doors. Exact date to be determined by construction company but already aware of need for screens to be replaced. Provider will update as soon as date determined. Estimated mid-December. |
12/31/2025
| Not Implemented |
| 6400.72(b) | On 10/22/2025 at 11:47 AM, the bottom mesh of the screen in the kitchen window located on the right side of the home was torn in an irregular-shaped area, measuring one-half inch by one-half inch. At 11:53 AM, the bottom left corner of the screen mesh in the window facing the front of the home located in Individual #1's bedroom was torn in a linear manner, measuring approximately one and one-half inches in length. | Screens, windows and doors shall be in good repair. | Provider will have contractor install properly fitted screens to all necessary windows/doors. Exact date to be determined by construction company but already aware of need for screens to be replaced. Provider will update as soon as date determined. Estimated mid-December. |
12/31/2025
| Not Implemented |
| 6400.73(a) | On 10/22/2025 at 12:02 PM, the basement's only exterior door opened to a vestibule containing seven steps that led to a set of Bilco doors; however, this set of stairs did not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Contractor has been notified by provider of need for handrail installation. Quote sent and approved by provider. Awaiting start date from contractor. |
12/31/2025
| Implemented |
| 6400.82(f) | On 10/22/2025 at 12:10 PM, the home's only bathroom did not include a trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Trash can purchased and placed in restroom on 10-30-2025. |
12/31/2025
| Implemented |
| 6400.105 | On 10/22/2025 at 11:49 AM, the dryer vent filter was covered in its entirety with a thick layer of lint, dust, and fabric particles. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Dryer lint filter was cleaned immediately at time of inspection. In the future, staff will clean vent filter each use to ensure no lint or dust present. |
12/31/2025
| Implemented |
| 6400.214(b) | On 10/22/2025 at 12:20 PM, neither hard nor electronic copies of the following regarding Individual #1's most current records were kept at home: The current Service Plan, incident reports, a dental examination, and an applicable psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Psychological evaluation was obtained and placed in the individual's file. |
11/01/2025
| Not Implemented |
| 6400.20(b) | The home did not review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | Trend analysis for first three quarters completed of 2025. IM representative will ensure continued compliance in the future. |
01/16/2026
| Not Implemented |
| 6400.32(r)(1) | On 10/22/2025 at 12:14 PM, the door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not provide Individual #1 with a unique mechanism or entry device to lock and unlock their bedroom 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. | Maintenance to replace doorknob as soon as possible with knob equipped with locking mechanism and key. Staff will educate individual how to lock and unlock her door. House managers will be conducting a monthly home inspection which will include ensuring doorknob works properly and that individual may lock and unlock her door. |
12/31/2025
| Implemented |
| 6400.32(r)(4) | On 10/22/2025 at 12:14 PM, the door lock to Individual #1's bedroom was equipped with a turn latch on the inside and a pinhole access point on the entry side. This bedroom door locking system does not allow easy and immediate access by Individual #1 and staff in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | Maintenance to replace doorknob as soon as possible with knob equipped with locking mechanism and key. Staff will educate individual how to lock and unlock her door. House managers will be conducting a monthly home inspection which will include ensuring doorknob works properly and that individual may lock and unlock her door. Staff will ensure key to individual's bedroom is accessible at all times and in the event of an emergency. |
12/31/2025
| Implemented |