| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(4) | At time of inspection a chest of drawers was not located in Individual #1's bedroom as required. A closet with clothing racks and shelves accessible to the individual was in the bedroom as required by 6400.81(k)5. A chest of drawers is required unless the individual has a behavioral need that could be exacerbated by one or more items. Such conditions must be documented in accordance with 6400.195. Notation that a dresser should not be in the Individual's bedroom was not included in the Individual Support Plan (ISP) last updated on 7/1/25. A dresser shall be in the bedroom unless all requirements are satisfied. | In bedrooms, each individual shall have the following: A chest of drawers. | A chest of drawers has been provided in the individual¿s bedroom. July 31, 2025. |
08/05/2025
| Implemented |
| 6400.112(d) | The fire drill completed on 7/6/25 documented an evacuation time of 2:38. This exceeds the 2:30 allowed. No other drills were held during the month. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All staff members providing care for the Individual were retrained on fire drill completion July 25, 2025. |
08/05/2025
| Implemented |
| 6400.186 | The Individual Support Plan (ISP) last updated on 7/1/25 notes that "The cla are using door chimes as a mitigation strategy when [Individual #1] leaves [their] apartment to ensure [their] safety. There were no operable door chimes on the door to the apartment at the time of the inspection.
(REPEAT VIOLATION 5/26/25) | The home shall implement the individual plan, including revisions. | New door chimes have been installed in Individual # 1 home July 26, 2025. |
08/05/2025
| Implemented |