| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 9/26/2024 at 11:01am, the rear basement egress was observed without a light fixture. No other exterior fixture could provide sufficient light to this egress. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Corrected during inspection. Maintenance installed light .Outside steps are now lighted. |
09/26/2024
| Implemented |
| 6400.81(h) | On 9/26/2024 at 11:12am, Individual #3's bedroom window did not permit a view to the outside. The window in the basement-level bedroom is a glass block window, with a frosted center pane. | Each bedroom shall have at least one exterior window that permits a view of the outside. | The window in the bedroom will be replaced with a new window that permits a view of the outside. A quote has been received and work is scheduled to begin on 11/13/2024. |
11/05/2024
| Implemented |
| 6400.81(i) | On 9/26/2024 at 11:12am, the window in Individual #3's bedroom did not have drapes, curtains, shades, blinds or shutters for privacy. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Curtains have been purchased and installed by the maintenance director on 10/14/2024. |
10/14/2024
| Implemented |
| 6400.110(b) | On 9/26/2024 at 11:15am, the closest smoke detector to Individual #3's bedroom measured 16.066 feet from the bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Maintenance has relocated the smoke detector to a position that is now 10.5 feet from the bedroom. |
10/04/2024
| Implemented |
| 6400.181(e)(8) | Individual #1's annual assessment, completed 7/18/2024, does not include an assessment of the individual's ability to evacuate in the event of a fire. Individual #1's assessment states, "[Individual #1] understands what a fire alarm is and what it is used for. She also understands that during a fire she is to exit the building immediately. [Individual #1] performs monthly fire drills at home and at CPS." | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Assessment completed as of 9/25/2024 to include the individuals ability to evacuate in the event of a fire. |
09/26/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's annual assessment, completed 7/18/2024, did not include a copy of the individual's psychological evaluation. Individual #1's psychological evaluation was completed on 3/24/1987 and was available at the agency office; however, the evaluation was not attached to the assessment and documentation could not be provided to verify that the evaluation was sent to the plan team. | The assessment must include the following information: Psychological evaluations, if applicable. | Psychological evaluation was obtained during inspection and placed in individuals file. |
09/26/2024
| Implemented |
| 6400.214(b) | On 9/26/2024 at 10:55am, the most current copy of Individual #1's support plan that was available on-site at the residential home was last updated on 6/8/2023 and covered the plan year spanning from 7/1/2023 through 6/30/2024. The most current plan available on the Home and Community Services Information System (HCSIS) was last updated on 5/31/2024 and covers the plan year spanning from 7/1/2024 through 6/30/2025. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Updated ISP is now in the file at the individuals home. |
09/26/2024
| Implemented |