| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On 10/8/2025 at 12:35PM, the door, on the right side of the cabinet under the sink in the kitchen of the home, was missing. On 10/8/2025 at 12:45PM, the doorknob on the door leading to Individual #1's bedroom was extremely loose, and the latch bolt was not secured, preventing the door from remaining closed. | Floors, walls, ceilings and other surfaces shall be in good repair. | QCH (CFO) installed the right side cabinet door under the sink and replaced the door knob and latch to ensure that all doors are in good repair. |
10/24/2025
| Implemented |
| 6400.104 | The provider agency mailed a notification letter to the local fire department on 2/1/2025. This letter includes inaccurate information regarding the layout of the home and the location of the individual's bedroom. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| QCH Human Resource Specialist revised and mailed the notification letter to the local fire department. QCH was trained by the Program Director on fire department notification letters and the importance of accurate information in the event of a fire on 10/24/2025. |
10/24/2025
| Implemented |
| 6400.32(r)(1) | On 10/8/2025 at 12:45PM, there was a thumb turn locking mechanism on the outside with a turn locking mechanism on the inside of the door to Individual #1's bedroom. Individual #1 has not been provided with a designated mechanism to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | QCH Maintenance removed thumb turn doorknob and replace it with a key lock doorknob. The individual was educated on their rights on having a door with a lock as well as their right to a key. The individual has the key and is kept on their person. the individual has been educated to report the the staff on duty if the key has been misplaced or lost. |
10/24/2025
| Implemented |
| 6400.32(r)(5) | On 10/8/2025 at 12:45PM, there was a thumb turn locking mechanism on the outside with a turn locking mechanism on the inside of the door to Individual #1's bedroom. Staff did not have a designated mechanism to unlock the door in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | QCH Maintenance removed thumb turn doorknob and replace it with a key lock doorknob. The individual was educated on their rights on having a door with a lock as well as their right to a key. The individual has the key and is kept on their person. In the event staff has to access the room in the event of a lost key or emergency, staff has a copy of the key. |
10/24/2025
| Implemented |