| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | On 10/2/2024 at 12:17pm, the hot water temperature in the full hallway bathroom measured 125.6°F when tested at the sink. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Staff adjusted the hot water temperature on the hot water tank and checked the temperature 3 times at all sinks and tubs and temperature did not exceed 120 degrees during any check. |
10/02/2024
| Implemented |
| 6400.66 | On 10/2/2024 at 12:36pm, no light fixture was present to provide sufficient lighting at the sunporch egress. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A light was installed on the sunporch egress. |
10/08/2024
| Implemented |
| 6400.68(b) | On 10/2/2024 at 12:18pm, the hot water temperature in the full hallway bathroom measured 128.1°F when tested at the bathtub. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Staff adjusted the hot water temperature on the hot water tank and checked the temperature 3 times at all sinks and tubs and temperature did not exceed 120 degrees during any check. |
10/02/2024
| Implemented |
| 6400.110(b) | On 10/2/2024 at 12:37pm, the closest smoke detector to the vacant bedroom, located in a common area of the home, measured 18.097 feet from the bedroom door way. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The smoke detector was relocated and is now within 15 feet of the bedroom doorway. |
10/08/2024
| Implemented |
| 6400.214(b) | On 10/2/2024 at 12:37pm, the most current copy of Individual #1's individual support plan that was located at the residential home was last updated on 4/18/2024 and covered the 7/1/2023 through 6/30/2024 plan year. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most current copy of the ISP was placed in Individual #1¿s file located in the locked cabinet in staff office. |
10/02/2024
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #2, date of hire 8/24/2024, did not participate in orientation training to encompass job-related knowledge and skills such as the implementation of the individual plan for the individuals they work directly with. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program Specialist was retrained on the importance of training and signing off on job related knowledge and skills training upon hire. |
10/03/2024
| Implemented |
| 6400.52(c)(6) | Program Specialist #1 did not participate in training to encompass the implementation of the individual plan for the individuals they work directly with during the 1/1/2023 through 12/31/2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Program Specialist was re-trained on the importance of signing off on training on the individual plan for herself as well as staff upon hire. |
10/03/2024
| Implemented |