| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | On 09/24/26, at 10:29 AM, Ortho Home Defense bug killer was located under the bathroom sink in Individual #1's bathroom attached to their bedroom. There was a child lock located on the knobs, but it was able to be taken off without unlocking it. Individual #2's ISP last updated 9/02/2025 states poisonous substances are to remain locked in the home at all times because Individual #2 is not aware of the dangers of poisonous substances [Repeat Violation 09/25/24, et. al.] | Poisonous materials shall be kept locked or made inaccessible to individuals. | The chemical was removed from the bathroom 9/24/2025. No chemicals will be kept in this bathroom going forward. |
10/02/2025
| Implemented |
| 6400.112(d) | The home completed a fire drill on 8/14/2025 with an evacuation time of 3 minutes and 41 seconds. The home does not have an extended evacuation time issued by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Since the fire drill conducted on 8/14/2025, two additional fire drills have been completed, and both evacuation times were under 2 ½ minutes. All staff working in this home will participate in a fire drill to ensure they are trained and able to evacuate individuals within the required timeframe. |
10/02/2025
| Implemented |
| 6400.181(e)(1) | On 09/24/25, at 10:36 AM, Individual #3 had a grab/assist bar located on the left side of the individual's bed. The need for this grab/assist bar was not documented in the individual's most current assessment dated 2/03/2025. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The grab/assist bar has been removed from the bed due to Individual #3 no longer utilizing it. The assessment will not require an update. |
10/06/2025
| Implemented |