| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(h) | On 10/02/2025 at approximately 2:36pm, the two windows in Individual #1's bedroom were covered in a frosted film that obstructed the entire view of the outside. | Each bedroom shall have at least one exterior window that permits a view of the outside. | All maintenance and all supervisors are informed that windows cannot be completely covered in privacy film as the windows must permit a view of the outside. Maintenance removed all window film from windows.
Corrections discussed in Supervisor meeting 10/8/25 and window film was removed on 10/8/25 |
10/08/2025
| Implemented |
| 6400.110(f) | On 10/02/2025 at approximately 2:38pm, the smoke detector on the ceiling, outside of Individual #2's bedroom door, was not interconnected with the strobe lighting in Individual #2's bedroom and the common areas of the home. Individual #2's individual support plan, last updated 6/02/2025, states "[the individual] has hearing loss in both ears and is supposed to wear hearing aids to assist with hearing. [Individual #2] will refuse to wear [their] hearing aids on most days and will often times lose them." | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | On 10/2/25, after licensing, it was brought to our attention that Vector ( alarm system monitoring removed an alarm from the ceiling and did not replace it. He was there switching out monitoring lines for sprinkler systems and backups. Maintenance installed a new one on 10/6/25. see photo. An email was sent to all management on 10/2/25 to alert management to new procedure. |
10/10/2025
| Implemented |
| 6400.216(a) | On 10/02/2025 at approximately 2:23pm, there was a binder on a cabinet, unlocked and accessible in the staff office, which included the following documents for Individual #1 and Individual #2: social and physical activity forms, medication administration record review forms, and medication reorder forms. At approximately 2:24pm, there was a plastic bin attached to the wall, unlocked and accessible in the staff office, which was labeled "outgoing mail" that included the following documents: Individual #2's physical examination completed 10/2/2025 and Individual #2's bloodwork order dated 9/2/2025. | An individual's records shall be kept locked when unattended.
| All house supervisors were informed that individual records must be kept locked when not attended during supervisor meeting on 10/8/25. A follow up email was sent on 10/9 to supervisors to clarify all individual information and an communication was sent electronically to all employees on 10/9/25. The requirement has been added to the weekly house visit form that supervisors utilize each week when visiting homes. An email was also sent out by the Assistant Program Director. |
10/09/2025
| Implemented |