| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | Obstructed egress. The rear/second exit from the home leads to the backyard which is completely fenced in. The one exit from the fenced yard has a keyed padlock on the inside of the gate which restricts the ability to evacuate from the yard in an emergency, as well as restricts access to the rear of the home by emergency responders. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The agency confirmed that the rear/second exit from the home led to a fenced yard with a keyed padlock on the inside of the gate, which obstructed egress and could delay emergency evacuation or responder access. The keyed padlock has been removed to ensure an unobstructed egress from the yard without the use of a key, tool, or special knowledge. The agency will ensure the exit path is always fully accessible |
02/25/2026
| Implemented |
| 6400.181(f) | The program specialist shall provide the assessment to the individual plan team members at least 30 days prior to the individual plan meeting. The annual individual plan meeting for Individual #1 was held on 11/20/2025 and the assessment was not provided to the team members until the day of the meeting, 11/20/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | On 11/20/2025, it was identified that the assessment for Individual #1 was not provided to the Individual Support Plan team members at least 30 calendar days prior to the annual ISP meeting, as required. The assessment was distributed on the date of the meeting instead of by the required deadline. The Program Specialist has been retrained on the regulatory requirement to provide assessments to team members at least 30 calendar days prior to the ISP meeting. A tracking system has been implemented to monitor ISP meeting dates and required assessment distribution deadlines. Going forward, assessments will be completed and sent to all team members no later than 30 calendar days before each scheduled ISP meeting. |
03/02/2026
| Implemented |
| 6400.195(a) | Individual #1 is deprived of free access to all parts of their home with the exception of those spaces that must remain locked for their safety, i.e. closets containing poisonous substances that the individual has been assessed as not able to safely use or avoid. At the time of the inspection, the bathroom located near the individual's bedroom was locked and staff reported that the individual has no need to access the bathroom since they wear adult briefs. Staff had keys to the bathroom and controlled whether the individual could access the bathroom. The individual does not have a restrictive procedure in place. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | The bathroom near Individual #1's bedroom was kept locked without an approved restrictive procedure in place. The door was unlocked immediately upon discovery. The Program Specialist, House Manager, and staff were retrained on individual rights and the requirement that restrictive procedures must be documented in the ISP and reviewed and approved by the Human Rights Team prior to implementation |
02/25/2026
| Implemented |