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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At 1:16 PM on 12/10/25, located within a recessed room of the basement, was a sump pump unit installed in an uncovered well or trench area dug into the floor that measured three feet in length, by two feet in width, by 20 inches in depth, and posed a tripping hazard. The access door to this recessed room where the sump pump is installed was not equipped with a lock. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Maintenance department installed a sump pump access cover and a keyed door knob to the recessed area. |
01/15/2026
| Implemented |
| 6400.52(a)(1) | Direct Service Worker #1, date-of-hire is 6/9/25, completed 18.9 hours of orientation training on 6/9/25 in the following required topics, which were documented on their College of Direct Supports transcript: "Person-Centered Planning" (2.0 hours), "Community Inclusion" (3.1 hours), "Individual Rights and Choice" (0.8 hours), "Individual Choice" (3.0 hours), "Positive Behavior Supports" (3.3 hours), "Developing and Maintaining Relationships" (1.7 hours), "Implementation of the ISP and Safe and Appropriate Use of BSP Training" (1.5 hours), "Fire Safety Training" (2.0 hours), "Employee Handbook & Policy Directive #32" (1.0 hours), and "Sexual Harassment Training" (0.5 hours). This does not meet the 24 hours of training required by regulation. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | The training department has started documenting all dates of training hours instead of just the completed date of the training to reflect an accurate record of Employee training hours completed in college of direct support and agency trainings. |
01/15/2026
| Implemented |
| 6400.186 | Individual #1's Service Plan, last updated 12/5/25, stated, "Poisonous materials are kept locked in the home for safety reasons." At 1:04 PM on 12/10/25, unlocked on an accessible shelf in the home's laundry room located off the kitchen were the following poisonous materials; a 208 fluid-ounce jug of Arm and Hammer Laundry Detergent; a 203.1 fluid-ounce jug of Xtra Laundry Detergent; a 2.75-quart bottle of Great Value Laundry Stain Remover; and a two quart bottle of Zep Premium Carpet Cleaning Shampoo. At 1:25 PM, unlocked and accessible underneath the sink of the home's only bathroom were the following poisonous cleaners: a 20 fluid-ounce spray can of Scrubbing Bubbles Bathroom Cleaner; a 32 fluid-ounce spray bottle of Great Value All-Purpose Cleaner with Bleach; a 21 ounce can of Comet Cleanser; and a 24 fluid-ounce bottle of Great Value Toilet Bowl Cleaner. | The home shall implement the individual plan, including revisions. | All poisonous cleaners were locked up on 12/10/25 in the staff room. |
01/15/2026
| Implemented |
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