| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(5) | At the time of inspection, individual #1 closet doors were unable to open and close easily. The bottom of the folding doors was getting caught on the carpet. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | CEO contacted contractor to replace closet door on 10/24/25. Contractor assured CEO that closet door will be replaced by 11/15/2025. |
12/01/2025
| Accepted |
| 6400.112(c) | The fire drill records for the home do not include problems encountered for any drill completed. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | CEO updated fire drill record form on 10/16/2025 to include a section titled "problems encountered" and informed all Residential team members on the same date of the change and how to complete the form (Fire Drill Attachment 1). A fire drill will be completed with the new form by 10/30/25 (Fire Drill Attachment 2). |
10/30/2025
| Accepted |
| 6400.181(e)(7) | Individual # 1's assessment dated 8/10/2025 does not identify the ability to sense heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Program Specialist updated assessment to include information regarding the ability to sense heat sources on 10/27/25 (Ind#1 Assessment 10-25 Attachment). |
10/28/2025
| Accepted |
| 6400.211(b)(3) | Individual #1 has a demographic/emergency information form but it does not identify a person who is able to provide emergency medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| House Supervisor updated demographic emergency medical consent information for Ind#1 on 10/27/25 (Ind#1 Face Sheet 10-25 Attachment). |
10/27/2025
| Accepted |
| 6400.166(a)(5) | Individual #1 MAR is missing dosage amount for Lamotrigine 100mg tablet for month of June 2025 and July 1st and 2nd, 2025. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Entire team was retrained by Carasolva electronic Medication Administration Record system on entry of items into the system, how to ensure information is entered accurately to ensure that the medication dosage on the bottle or blister pack matches what is listed in Carasolva electronic Medication Administration Record (eMAR) on 10/28/25 (Carasolva Training Signature 10-28-25 Attachment) . |
11/30/2025
| Accepted |