| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 5/20/2026 at 1:10pm, there was insufficient lighting at the egress leading from the attached garage to the left side of the home. A light fixture was observed above the exterior doorway; however, the fixture was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| House Manager submitted maintenance ticket upon discovery on 5/20/2026. Priority Electric contacted and scheduled to assess by 6/12/2026. |
06/12/2026
| Implemented |
| 6400.181(a) | Individual #1, date of admission 12/8/2025, had an initial assessment completed by Program Specialist #1; however, this assessment was not dated. Therefore, compliance could not be measured. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The initial assessment for Individual #1 was reviewed, and Program Specialist received retraining on the requirement to date all assessments at the time of completion by Program Director on 5/22/2026. |
05/22/2026
| Implemented |
| 6400.181(d) | Individual #1, date of admission 12/8/2025, had an initial assessment completed by Program Specialist #1; however, this assessment was not dated. | The program specialist shall sign and date the assessment. | The initial assessment for Individual #1 was reviewed, and Program Specialist received retraining on the requirement to date all assessments at the time of completion by Program Director on 5/22/2026. |
05/22/2026
| Implemented |
| 6400.32(r)(1) | On 5/20/2026 at 1:15pm, Individual #2's bedroom door was observed with a pinhole locking mechanism that does not have a unique locking mechanism to include a key, access card, keypad code or other entry mechanism to permit the individual to lock and unlock their door. On 4/29/2026, Individual #2 signed the agency's door lock declination form and indicated that they were "choosing to have a lock on [their] bedroom door." The agency violated Individual #2's right to lock their bedroom door by not providing them with a unique locking mechanism. | 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. | Program Specialist or designee will meet with all individuals who reside in the home. For those individuals who choose to have a lock on their door a knob with a unique key will be installed and the individual and staff will be given a key. For those who indicate that they do not want a lock on their door a passage door knob will be installed in accordance with their rights and personal choice as documented on their signed locked doors form. Staff to be retrained by July 1, 2026 on client lock preferences. |
07/01/2026
| Implemented |
| 6400.182(c) | Individual #1's initial undated assessment indicated that they had the ability to independently evacuate in the event of a fire; however, their support plan, last updated 4/23/2026, stated "[Individual #1] would require assistance from [their] family or staff to safely evacuate in the event of a fire emergency." Individual #1's support plan had not been revised based upon the current assessment. [Repeated violation: 5/28/2025 et al] | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual number #1 is able to demonstrate the ability to evacuate independently. Program Specialist to send ISP Change Form to be sent for a language update indicating successful fire evacuation independently by 6/15/2026. |
06/15/2026
| Implemented |