| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water in the bathroom reached a temperature of 125.2 degrees | Hot water temperatures in bathtubs and showers may not exceed 120°F. | the house manager contacted maintenance to turn the water temperature down. completed by building maintenance. |
02/02/2026
| Implemented |
| 6400.81(k)(5) | Individual #1 does not have a closet or wardrobe in his room. The individual is using a closet just outside of the bedroom, however if this is the individual's preference, it needs to be documented in the individual's plan. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | The residential director purchased a chest of wardrobe drawers for the bedroom. |
02/02/2026
| Implemented |
| 6400.81(k)(6) | There is no mirror in the bedroom of individual #1 | In bedrooms, each individual shall have the following: A mirror. | Per the isp and safety concerns, the individual cannot have a mirror. |
02/02/2026
| Implemented |
| 6400.112(d) | The fire drills did not document the duration of the evacuation | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | The fire drill log has the evacuation start time and end time. |
02/02/2026
| Implemented |