| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The exterior light located at the rear exit of the home was not working at the time of the inspection.
((REPEAT VIOLATION 5/20/2024)) | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| QLHS maintenance staff has repaired the exterior light that was located in the rear exit of the home to ensure the health and safety of the individual in the home to avoid accidents. |
06/16/2025
| Accepted |
| 6400.73(a) | The basement bilco-door style exit had more than two steps and there was no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | QLHS designated person will repair handrail from outside backsteps from the kitchen to ensure the health and safety of the individual served by QLHS. |
07/30/2025
| Accepted |
| 6400.80(b) | Exterior conditions of the home shall be well-maintained and free of unsafe conditions. The back yard of the home was in poor condition with long grass and weeds located near the foundation and back porch that were taller than waist-high and there was a pile of rubble and debris located within the weeds near the foundation.
((REPEAT VIOLATION 5/20/2024)) | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | QLHS maintenance personnel has cut the grass located in the back yard of the home and removed all weeds, the piles of rubble and debris |
07/16/2025
| Accepted |
| 6400.106 | Furnaces shall be inspected and cleaned at least annually. A furnace inspection and cleaning occurred on 2/02/2024, then again on 4/07/2025 which is a greater time span than the required 365 days, plus a 15-day grace period. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| QLHS designated person will schedule an appointment to have the furnace checked to ensure the health and safety of the individual served. |
07/30/2025
| Accepted |
| 6400.112(c) | The fire drill record for the fire drill conducted on 6/17/2024 did not document the exit route used.
((REPEAT VIOLATION 5/20/2024)) | 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. | QHS will retrain staff on how to fill out the fire drill forms, and its entirety as required by QLHS and ODP. Also to ensure that the individual is evacuating the home in a timely manner as stated in ODP regulations. |
07/30/2025
| Accepted |
| 6400.112(e) | A fire drill must be held during sleeping hours at least every six months. There were no fire drills conducted during sleeping hours in the past year. All monthly fire drills from June 2024 to the present were held during waking hours.
((REPEAT VIOLATION 5/20/2024)) | A fire drill shall be held during sleeping hours at least every 6 months. | QLHS will retrain staff on conducting a fire drill during sleep hours to ensure the health and safety of the individuals we serve. |
08/01/2025
| Accepted |
| 6400.15(b) | The provider did not utilize the Department's licensing inspection instrument (form) when completing the self-assessment to measure record compliance of this home. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | QLHS Director that completed the self-assessment form has been shown where to find the correct inspection instrument self-assessment measure form. |
07/01/2025
| Implemented |