| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The exterior light at the backdoor was not functional. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Light bulb was replaced in the exterior light at the backdoor. |
11/19/2024
| Implemented |
| 6400.70 | There was no working landline phone. Staff reports that one of the individuals habitually unplugs the base for the cordless phone that is stored in a cabinet in the kitchen. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Site will purchase cordless phones with one being upstairs in the residence and one being downstairs in the residence. |
01/01/2025
| Implemented |
| 6400.71 | There were no emergency numbers posted in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency Numbers were posted on the same day of the licensing visit upon notification. |
11/19/2024
| Implemented |
| 6400.81(k)(6) | There was no mirror in Individual #3's bedroom. | In bedrooms, each individual shall have the following: A mirror. | A mirror will be purchased and placed in Individual #3 bedroom. |
12/15/2024
| Implemented |
| 6400.151(a) | Staff Person #4 was hired on 1/11/2021 and a physical was completed on 1/8/2021. A physical should have been completed by 1/8/2023 and a physical was not found in the record since the initial physical. | 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. | COMHAR's Credentialing Coordinator will monitor the ID Residential Rosters to ensure all physicals are current per the two year requirement. Three months prior to the physical expiring, the Credentialing Coordinator will start reaching out to the staff member for completion. |
12/01/2024
| Implemented |
| 6400.216(a) | The individuals' books were left out on top of a filing cabinet in the dining room. | An individual's records shall be kept locked when unattended.
| Individual books were placed in the locked medicine cabinet. |
11/19/2024
| Implemented |