| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | Individual #1's bedroom windows and the bathroom windows of the home are unable to be opened to allow ventilation. The windows are completely sealed with plexiglass over the frame to prevent Individual #1 from access where the windows can potentially be broken. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Work order for maintenance was submitted for the winder to be fixed or replaced on 1/5/26. |
01/05/2026
| Implemented |
| 6400.67(a) | Cabinets are not in good repair. The cabinet next to the stove in the kitchen is broken and missing a hinge. | Floors, walls, ceilings and other surfaces shall be in good repair. | Provider fixed the cabinet on 1/6/26. |
01/06/2026
| Implemented |
| 6400.67(b) | Doors are not in good repair. The bedroom door on Individual #2 and Individual #3's bedroom door is broken and cannot be closed without lifting the door.
The carpet on the steps leading to the bedrooms in the home on the first step going up the stairs is worn and protruding up and presents a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Bedroom doors were fixed on 1/6/26. |
01/06/2026
| Implemented |
| 6400.72(a) | Individual #1's bedroom window does not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Work order within the provider was completed on 1/5/26 for a screen to be installed on the winder. |
01/05/2026
| Implemented |
| 6400.141(c)(4) | Individual #1 did not have an annual hearing screening completed. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Provider will contact PCP to schedule screening on 1/14/26. |
01/14/2026
| Implemented |
| 6400.141(c)(5) | Individual #1 was not up to date with Tdap vaccine. Individual #1 was due to receive a tetanus vaccine on 12/15/25. Individual #1 did not receive the vaccine until 12/29/25. This was outside of the 15-day grace period that is permitted for physical examinations. | The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. | The vaccine was administered on the 29th of December 2025. Documentation is on file. |
12/29/2025
| Implemented |
| 6400.144 | Individual #1 is prescribed Klonipin PRN. Individual #1 has a protocol for when the medication is to be administered, however the protocol does not include who is to be contacted in order to give permission to administer the medication. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Action plan on administration of medication was completed. PCP desires to see the individual prior to signing the letter on administration of medications. Appointment with PCP was scheduled for 2/2/26 |
02/02/2026
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of psychiatric illness. Individual #1 did not have a 3-month review of medications. Individual #1 had a review of these medications on 1/22/25 and did not have a review of these medications until 5/5/25. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Staff will be retrained on timeliness of appointment by 1/23/26 |
01/23/2026
| Implemented |