| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 11/25/2025 at 12:48PM, Tide Laundry Pods and a spray bottle of Shout Stain Remover were unlocked and accessible in a cabinet above the washer and dryer in the laundry room at the back entrance of the home. At 1:01PM, multiple bottles of Lysol All Purpose Cleaner, Clorox Scentiva, Mr. Clean Clean Freak Multi-Purpose Cleaner, Lysol Disinfectant Spray, Member's Mark Floor Cleaner and Degreaser, Easy Off Oven Cleaner, Hot Shot Ant, Roach and Spider Killer, Fabuloso Multi-Purpose Cleaner, Scrubbing Bubbles and Great Value Furniture Polish. Individual #1's assessment, completed 11/3/2025, instructs that Individual #1 needs "physical prompts" to safely use poisons. Individual #1's service plan, last updated, 10/15/2025, reads, "[Individual #1] does not know safety precautions. Nothing can be left out because [Individual #1] will get in to it. Poisonous items need to be kept locked at all times. [Individual #1] does not understand the sign for poisons nor would [Individual #1] use them appropriately." | Poisonous materials shall be kept locked or made inaccessible to individuals. | 6400 62(a) - Poisonous materials shall be kept locked up or made inaccessible to individuals.
Immediate: Individual #1 does not need to have poisons/chemicals locked up. This was confirmed with all of his team members and updated/revised in the individual's ISP that matches the 6400 residential assessment. The changes were verified by Program Specialists in HCSIS and confirmed via e-mail from the Support Coordinator. Individual #1's updated ISP will be sent as an attachment with the date it was changed and the changes that were made will be highlighted. |
12/19/2025
| Implemented |
| 6400.67(b) | On 11/25/2025 at 12:56PM, there was a three-foot by four-foot puddling of water on the floor near the door in the basement of the home which appears to be coming in from the outside posing a slipping and falling hazard. At 12:58PM, there was no transition strip in the doorway in the kitchen leading to the basement of the home posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | New steel Bilico Doors have been ordered on 12/10/25 to replace old wooden storm door. Delivery Scheduled 12/26/25
Installation completed: 12/18/25 photo proof in attachments
Floor installed to basement landing to even out the transition and new transition strip installed 11/26/25. Photo Proof in attachments |
12/18/2025
| Implemented |
| 6400.101 | On 11/25/2025 at 1:35PM, there was a slide lock on the door in the kitchen leading to the basement of the home. At 1:38PM, there was a slide lock on the Bilko doors at the exit in the basement of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Valley Maintenance Department removed lock on basement door on 11/25/25. Photo Proof in attachments |
11/25/2025
| Implemented |
| 6400.216(a) | On 11/25/2025 at 1:06PM, a binder containing Individual #1's personal, identifiable information and health insurance cards was unlocked and unattended on a shelf in the living room on the first floor of the home. At 1:32PM, a binder containing Individual #1's personal identifiable information, service plan and Restrictive Procedure Plan was unlocked and unattended on a shelf in the staff office on the second floor of the home. | An individual's records shall be kept locked when unattended.
| Immediate (POC)
Record Relocation and Security
Records pertaining to Individual #1 were removed from their previous location and returned securely to the office. At the office, these records are kept locked at all times when not actively in use, safeguarding sensitive information and maintaining privacy. Completed11/26/2025
Furniture Acquisition and Installation
Lockable furniture was purchased and delivered (Order #1191802025) to further enhance the security of Individual #1's records. This furniture will be assembled and installed in the Downstairs Common Area, providing a dedicated and secure storage solution. The addition ensures both privacy and security for the records.
Efficiency for Direct Support Professionals (DSPs)
The strategic placement of secure furniture in the Downstairs Common Area will facilitate more efficient documentation processes for Direct Support Professionals (DSPs). DSPs will be able to complete, retrieve, and review documentation seamlessly while providing support in this area. |
11/25/2026
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 11/3/2025, states that Individual #1 needs verbal and physical prompting to regulate water temperature. Individual #1's service plan, last updated 10/15/2025, reads, "[Individual #1] does know water temperature. [Individual #1] knows when water is too hot or too cold." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 6400 182(c) - The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.¿
Immediate: Individual #1 does need physical assistance in tempering his water. This was confirmed with team members and has been updated/revised in the¿individual ISP so that it matches the 6400 residential assessment. The changes were verified by Program Specialists via HCSIS and confirmed via e-mail from the Support Coordinator. Individual #1's updated ISP and Residential Assessment will be sent as an attachment with the date it was changed as well as the changes made will be highlighted. |
12/18/2025
| Implemented |