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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | At 12:08 PM, the finish on the outside face of the garage's exterior swing door leading to the backyard was significantly cracked, peeled, and bubbled throughout the door's entire surface, exposing splintered paint chips. | Screens, windows and doors shall be in good repair. | The maintenance personnel was contacted to replace the door . |
03/13/2026
| Implemented |
| 6400.101 | At 12:05 PM on 2/19/26, in addition to a standard door lock assembly, the interior side of the attached garage's exterior swing door leading to the backyard was equipped with a sliding chain lock, creating a blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The maintenance personnel was contacted to remove the chain lock off the door. |
03/04/2026
| Implemented |
| 6400.104 | The agency did not submit written notification to the local fire department for this home to address the following: the home's address and the exact bedroom location(s) of any individual(s) who require assistance to evacuate in an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter to the local fire departments in the locations of our homes received a letter with the following information:
a. Name of the home
b. The address of the home
c. The municipality of the home
d. A description of the services provided
e. The location of the person's bedroom
f. The capabilities of the person who resides in the home to exit in case of a fire |
03/05/2026
| Implemented |
| 6400.32(r)(1) | At 12:22 PM on 2/19/26, Individual #1's bedroom door was equipped with a locking system requiring a key to disengage it from the outside. Agency interviews revealed that Individual #1 does not have a key to unlock and lock their bedroom and that only staff are in possession of the key. However, on 1/5/26, Individual #1 signed a form that read: "[Individual #1] accepts a key for [their] bedroom door." | 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. | The lock and key form will be updated and an option to select "the person we support has a lock on their bedroom door but does not wish to have a key"
The Program Director will keep up to date records of who has a lock on their door and does not want a key
If someone wishes to have an alternative to a key lock other arrangements will be made |
03/10/2026
| Implemented |
| 6400.50(a) | Direct Service Worker #1's annual training records for the 2025 calendar year did not document the trainer source of who facilitated such training in the following required topics and completion dates: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 4/5/25; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse on 4/5/25; individual rights on 4/5/25; recognizing and reporting incidents on 4/5/25; the safe and appropriate use of behavior supports regarding individual-specific reviews of such support plans on 12/30/25; and implementation of the individual plan regarding individual-specific reviews of such service plans on 12/30/25. Direct Service Worker #1's record of annual fire safety training, completed on 9/7/24, and then again on 9/4/25, did not document the content used, prepared and/or published by a fire safety expert(s). Program Specialist #2's annual training records for the 2025 calendar year did not document the trainer source of who facilitated such training in the following required topics and completion dates: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 4/9/25; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse on 4/9/25; individual rights on 4/9/25; recognizing and reporting incidents on 4/9/25; the safe and appropriate use of behavior supports regarding individual-specific reviews of such support plans on 12/30/25; and implementation of the individual plan regarding individual-specific reviews of such service plans on 12/30/25. Program Specialist #2's record of annual fire safety training, completed on 9/7/24, and then again on 9/4/25, did not document the content used, prepared and/or published by a fire safety expert(s). Chief Executive Officer #3's annual training records for the 2025 calendar year did not document the trainer source of who facilitated such training in the following required topics and completion dates: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 4/15/25; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse on 4/15/25; individual rights on 4/15/25; recognizing and reporting incidents on 4/15/25. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Training source has been added to all training records.
The title of the training video has been added to the fire safety training form |
03/10/2026
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1 had training in general fire safety 7/5/22 and then again 9/9/23. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 1. Individual had completed fire safety training., although late, so it does not need to be completed at this time.
2. Program Director will create at schedule of when all people in the community homes program should receive fire safety training.
3. Program Director will post the schedule in a place where all Program Specialists can access information.
4. Program Director will give a 30-day reminder notice to the Program Specialist that the training is due. |
05/24/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill records for fire drills conducted 7/28/21 through 7/6/22 did not include problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Fire Drill Log was revised to include a designated section to note problems encountered. Program Specialists received training on the revised form on 7/20/2022. Revised forms will be placed in the homes by 7/22/2022. |
07/22/2022
| Implemented |
| 6400.52(c)(1) | Chief Executive Officer #1, Direct Service Worker #2 and Direct Service Worker #3's annual training for training year 01/01/21-12/31/21 did not include: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships is on the training syllabus and will be provided to all staff by 9/30/2022. |
09/30/2022
| Implemented |
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