| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(b) | There was no smoke detector within 15 feet of Individual #1's bedroom. The closest smoke detector was approximately 20 feet from the bedroom. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | On October 16, 2025, the fire safety trainer installed a smoke detector in the hallway 15 feet from the individual's bedroom door, ensuring full compliance with 6400.110(b). The detector was tested at the time of installation to confirm functionality and proper alarm response. |
10/16/2025
| Implemented |
| 6400.181(a) | Individual #1, date of admission 6/23/25 had an initial assessment completed on 9/25/25. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | On October 15, 2025, the Program Specialist developed an assessment review log to ensure that the individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. |
10/15/2025
| Implemented |
| 6400.34(a) | Individual #1, date of admission 6/23/25, was informed and explained individual rights on 6/24/25. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | On October 21, 2025, the CEO trained the Program Manager and Home Supervisors on the need to discuss individual rights with the individuals on the date of admission. |
10/21/2025
| Implemented |