| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1's fire safety training, completed on 7/11/25, did not include instruction on site-specific evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The individual completed an updated fire safety training that includes content related to their place of residence: evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking procedures if the individuals smoke at home.
The updated fire training safety training signed by the individual will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.141(a) | Individual #1 had physical examinations completed on 5/13/24, and then again on 6/9/25. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | - Documentation of the completed medical evaluation has been obtained and filed in the individual¿s record.
- The House Manager verified that individual has an annual physical appointment scheduled for 6/1/26. |
09/05/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, dated 6/9/25, did not include their medication regimen. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | - Individual¿s physician was contacted, and a medication regimen was completed.
- Documentation of the review was obtained and added to the individual¿s record. |
09/05/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 6/9/25, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | - Individual¿s physician was contacted and a medication of medical information pertinent to diagnosis and treatment in case of emergency was completed.
- Documentation of the review was obtained and added to the individual¿s record. |
09/01/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, dated 4/22/25, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | A lifetime medical history was developed for the individual. Individual's developed lifetime medical history will be sent to the Department. |
09/05/2025
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment, dated 4/22/25, did not include an applicable psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | In the future, the Program Specialist will submit an assessment cover page to the individual¿s Support Coordinator and treatment team, which includes the following:
o Lifetime Medical History
o Yearly Doctor Appointments
o Psychological Evaluation
o Current List of Medications
A copy of the Assessment Cover Page Checklist will be sent to the Department. |
09/01/2025
| Implemented |
| 6400.32(r)(1) | The locking mechanisms on the bedroom doors of Individual #1 and Individual #2 are thumbnail, straight-edge turn locks with pop locks on the bedroom side of the doorknobs. This type of locking mechanism does not have a key, access card, keypad code, or other entry mechanism accessible to the individual to permit the individual to unlock and lock the door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | A request for a new locking mechanism system on the bedroom doors of Individual1 and Individual 2 from the property manager has been requested. |
09/15/2025
| Implemented |
| 6400.32(r)(4) | The locking mechanisms on the bedroom doors of Individual #1 and Individual #2 are thumbnail, straight-edge turn lock with pop locks on the bedroom side of the doorknobs. The locking mechanism does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | A request has been submitted to the property manager for permission to install a straight-edge turn lock with pop locks on the bedroom side of the doorknobs to allow immediate access by the individual and staff in the event of an emergency. |
09/15/2025
| Implemented |