| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.76(a) | The kitchen Faucet is shaky. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Faucet was fixed per video. |
10/03/2025
| Implemented |
| 6400.112(a) | 7 out of the 12 monthly fire drills were held in the presence of Individual #1 during the past twelve months. The Individual does not reside in this home. The agency stated that the individual likes to help with fire drills and therefore this acts to announce to the residents of the home that there will be a drill held during Individual #1's visit. | An unannounced fire drill shall be held at least once a month. | ·All staff were retrained on 9/5/2025 with 6400 regulations fire safety section. A sleep fire drill and awake was completed to show the individuals that only reside in the home participated in the drills. |
10/06/2025
| Implemented |
| 6400.112(e) | Over the past 12 months a drill was not conducted during sleeping hours. | A fire drill shall be held during sleeping hours at least every 6 months. | ·All Staff members completed retraining on Section 6400 of the fire safety regulations on September 5, 2025. Provider carried out a sleep-mode fire drill using the facility's actual address and layout, full participation with the individuals residing in the home |
10/06/2025
| Implemented |
| 6400.151(a) | Pre-employment physical not completed as a rehire for Staff Person #2. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | 9/3/25 Program Specialist contact staff person #2 to receive a copy of her current physical. Her Physical completed 3/10/2024 and 3/10/2025. A copy of document has been placed in individual #2 Staff Peron file. |
09/05/2025
| Implemented |
| 6400.151(c)(3) | The most recent physical does not indicate if staff is free from communicable diseases for Staff Person #1. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff is no longer with the Agency and has not retuned any calls or texts. |
09/05/2025
| Implemented |