| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(c) | On 9/4/2025 at 11:15am, seven large black trash bags full of garbage were found in the garage. The bags were not in trash receptacles. Staff stated the scheduled garbage pick-up was 9/3/2025. | Trash shall be removed from the premises at least once per week. | The trash bags were removed from the premises. |
09/09/2025
| Implemented |
| 6400.67(b) | On 9/4/2025 at 11:16am, trails of water were coming from the back left corner of the garage leading approximately 5-feet towards the middle of the garage and under a cabinet on the left wall. | Floors, walls, ceilings and other surfaces shall be free of hazards. | A plumber was called to investigate the water leakage on 9.9.25. He said it was an internal issue with the pipes. We are gathering quotes from other plumbers. |
11/03/2025
| Implemented |
| 6400.72(b) | On 9/4/2025 at 11:09am, in individual #1's bedroom, the screen in the window on the side of the house has a tear approximately 5 inches long across the top middle portion of the screen and a 2-inch tear in the middle of the screen. | Screens, windows and doors shall be in good repair. | The Maintenance Director repaired the holes in the screens. |
09/19/2025
| Implemented |
| 6400.80(a) | On 9/4/2025 at 10:52am, the walkways leading from the back of the home to the front were covered with moss. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The walkways were cleaned so they are no longer covered in moss. |
09/19/2025
| Implemented |
| 6400.80(b) | On 9/4/2025 at 10:52am, the white fence in the back and the side of the house was not in good repair and leaning. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The pieces of fence were cleaned up. |
09/19/2025
| Implemented |
| 6400.166(a)(13) | On 9/4/2025 at 10:39am, the initials "BP" administered the medication on 9/2/2025 for the 6:00am and 8:00am medication administration times, for individual #1. The name of the staff could not be identified because it was not on the signature pages of the medication administration record. Also, there was no master signature sheet for staff to identify signatures and initials. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The DSP was written up for failure to sign the MAR. |
09/04/2025
| Implemented |
| 6400.181(f) | The initial assessment for individual #1 was sent to the plan team on 11/5/2024 but not signed by Program Specialist #1 until 11/7/2024. Therefore, the assessment the Program Specialist provided to the plan team was incomplete. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist will be retrained on this regulation. |
09/25/2025
| Implemented |