| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.75(a) | There is not a landing beyond the interior door in the hallway that opens directly into the stairway leading to the basement of the home. | A landing shall be provided beyond each interior and exterior door that opens directly into a stairway. | On February 28, 2024, the interior door in the hallway that opens directly into the stairway leading to the basement was removed by Maintenance Personnel. All other homes were checked for compliance to ensure there is landing provided beyond each interior and exterior door that opens directly into a stairway |
03/01/2024
| Implemented |
| 6400.81(g) | Individual #1's bedroom is being used as a passageway to the ensuite bathroom which is the only bathroom in the home. | A bedroom may not be used by other individuals or staff persons as a regular or frequent passageway to another part of the home or to the outdoors. | Upon discovery, staff on-shift were contacted and instructed not to use individual¿s bedroom as an access point for the restroom. Instead of using the bedroom as a through-way, staff were advised to use the entry way from the common area to access the restroom. |
03/22/2024
| Implemented |
| 6400.214(b) | The most recent copies of Individual #1's assessment, dental examination, vision examination and psychiatric evaluation were not present at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The individual¿s assessment, dental examination, vision examination and psychiatric evaluation were uploaded to her electronic record on 2/28/24. |
03/24/2024
| Implemented |
| 6400.32(r)(3) | Individual #1's bedroom door is equipped with a pinhole locking mechanism doorknob. Individual #1 has not been given a mechanism and instruction to lock and unlock the bedroom door. | Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. | On 2/28/24, the individual was provided with the mechanism to open the pin hole lock and taught how to properly lock/unlock the door. Individual was able to successfully complete this task independently and replicate the process several times. |
02/28/2024
| Implemented |