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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | On March 20, 2025, at 11:41 AM, the five steps leading from the sidewalk running along the right side of the home to the rear exit of the home did not have a well-secured handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | To comply with 6400.73, the agency installed a handrail for the steps connecting the back yard with the side yard at Highland House on 3/26/2025. |
04/22/2025
| Implemented |
| 6400.110(e) | On March 20, 2025, at 12:02 PM, the first-floor smoke detector was not interconnected with the basement and second floor smoke detectors. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The Highland House interconnected smoke alarm that malfunctioned was replaced on 3/22/2025. |
03/22/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 4/12/2023 the exit to the back yard of the home, did not have operable lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 4/13/2023, the Director had a motion-sensor light placed near the back door. (Pic #9) The House Supervisor was retrained on the Lighting, Surfaces, Unobstructed Egress Policy on 4/13/2023. (Pic #15) [Documentation via photograph of a motion-sensor light placed outside of the rear entrance/exit of the home was received on 5/10/23 and reviewed 5/22/23. Documentation of training, dated 4/13/23, related to "Lighting, Surfaces, and Unobstructed Egress" was received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.101 | On 4/12/2023 the basement storage room containing poisons, had a padlock on the outside of the door presenting an entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Director spoke to the House Supervisor on 5/4/2023 to remove the padlock on the small basement storage room. The padlock and the poisons were removed. (Pic #6) [Documentation via photograph of the removed pad lock and poisonous materials was received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff, completed between 5/6/23 and 5/9/23, related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.112(f) | The fire drills completed 10/20/2022 and 1/11/2023 states the individual used the garage door as the exit route. The garage does not contain a swing door as an egress. | Alternate exit routes shall be used during fire drills. | The Fire Drill form and the Fire Drill Policy was updated on 5/4/2023 (Pic #5) to include the statement that a garage door cannot be used as a fire drill exit. A fire drill using the updated form was run on 5/4/2023 with all individuals present. (Pic #7) Staff discussed with the individuals that they would not be using the garage door as a fire drill exit. [Documentation of the Fire Drill Policy and TLHHC Monthly Fire Drill Report were received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff, completed between 5/6/23 and 5/9/23, related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.32(r)(4) | Individual #1 had a privacy lock on their bedroom door which 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. | The Privacy Lock Policy was updated on 5/4/2023 to include the updated language that bedroom doors should be equipped with a key lock to the outside and a doorknob tab on the inside. (Pic #10) The bedroom door¿s doorknob was replaced with a key lock on the outside and a doorknob tab on the inside on 5/6/2023. (Pic #11) The individual was trained on the updated policy on 5/6/2023. (Pic #12) [Privacy Lock Policy that includes that "[d]oors shall be equipped with a key lock on the outside and a thumb-turn lock on the inside" was received on 5/10/23 and reviewed 5/22/23. Documentation via photograph that a door lock, in accordance with the agency's policy, has been installed was received on 5/10/23 and reviewed 5/22/23. Documentation that Individual #1 was retrained on the Privacy Lock Policy, dated 5/6/23, was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
06/04/2023
| Implemented |
| 6400.186 | Individual #1's assessment completed 12/06/2022 states the individual is able to evacuate independently. Individual #1's individual support plan (ISP), last updated 1/04/2023, states the individual needs verbal prompts to evacuate. | The home shall implement the individual plan, including revisions. | The Program Specialist reviewed the individual¿s ISP and spoke with the individual and staff. Staff confirmed that the individual may need a verbal prompt to evacuate. The Program Specialist revised the 6400 Assessment on 5/4/2023 to read that the individual may need a verbal prompt to evacuate a fire. (Pic #13) The Program Specialist emailed the revised assessment to the ISP team on 5/8/2023. (Pic #14) [Documentation of Individual #1's updated assessment, dated 5/4/23, was received on 5/10/23 and reviewed 5/22/23. Documentation of communication of Individual #1's updated assessment to plan team members, dated 5/8/23, was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
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