| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The notification documentation provided 7/01/2025 to the local fire department documented Individual #1 is independent and does not need assistance in evacuating in the event of an actual fire. Individual #1's individual support plan, last updated 5/03/2026, documents "[Individual #1] is aware of the fire alarm but staff does need to direct [the individual] out of the house if there is a fire. Due to the seizure disorder, there cannot be strobes on the fire alarm. [The individual] needs others to prevent him from touching flames. During emergencies, [the individual] would need to be physically walked or carried out of the house to evacuate. If he is rushed or people are yelling or an alarm is sounding, he will not move." Individual #1's assessment, completed 1/19/2026, documents the individual requires physical prompts to exit the home in the event of a fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Upon learning of the discrepancy, the Director of Operations immediately corrected the notification letter and mailed it to the individual's local fire department. (see attached) |
06/17/2026
| Implemented |
| 6400.112(c) | The record for the 5/17/2026 fire drill did not include problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Upon learning of the discrepancy, the Director of Operations immediately revised the provider's Fire Drill form to include a "problems encountered" column. (see attached) |
06/17/2026
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 1/19/2026, documents the individual's recommendations for specific areas of training, programming, and services as not applicable. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Upon learning of the discrepancy, the Program Specialist reviewed and corrected the assessment and emailed the revised version to the individual's SC. (see attached) |
06/29/2026
| Implemented |
| 6400.214(b) | The following records were not in the home for Individual #1: current individual support plan and current psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Upon learning of the discrepancy, the Program Specialist immediately printed the ISP. The individual does not have a standard psychological evaluation; however, the individual's school assessments were present. |
06/18/2026
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 5/03/2026, documents "[Individual #1] needs to be within eyesight around all sharp objects···all sharp objects are locked···doors and windows need to be locked at all times in the vehicle with the child lock setting." Individual #1 does not have a restrictive procedure plan implemented and is not restricted with sharps and child lock settings in the vehicle. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Upon learning of the discrepancy, the Program Specialist reviewed the ISP, located the discrepancy and emailed the individual's SC requesting removal of the incorrect information. The Program Specialist also ensured that the documentation request mirrored the information in the individual's assessment. (see attached) |
06/29/2026
| Implemented |