| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | Individual #1's Service Plan, last updated 9/25/25, states that "[Individual #1] is able to evacuate independently during a fire drill if [they] [have] [their] hearing aids [and] in case of a fire, [Individual #1] should be visually monitored to see if [they] [have] [their] hearing aids and [that] [they] [are] aware of the danger." Therefore, Individual #1 requires assistance to evacuate in the event of a fire. Furthermore, the home's Fire Department Notification Letter, dated 8/29/25, indicated that the two residing individuals require verbal assistance to evacuate. However, the home's Fire Department Notification Letter, dated 8/29/25, was not kept current, as it did not include the following: indication that Individual #1 requires visual monitoring to determine if they aware of the danger in the event of an actual fire; and the exact bedroom locations of the two residing individuals, as this letter stated vaguely that "the bedrooms are located on the right side of the house." | 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.
| Laurel House, Inc is currently getting layout designs of all residential sites that will show where bedrooms are located in all of our residential sites. Once all updated information is obtained, New Fire Department letters will be mailed out that contain maps of the residential sites with bedroom locations and exits clearly marked. The letter will also state if the individuals require physical assistance when evacuating the residential home. |
11/26/2025
| Implemented |
| 6400.171 | At 9:56 AM on 10/3/25, the following food items in the kitchen pantry located next to the bathroom on the home's main level were open, unsealed, and unprotected from contamination: a one-pound cereal box of Honey Nut Cheerios; and a 10.8-ounce cereal box of Honey Nut Cheerios. [Repeated Violation-11/13/24, et al] | Food shall be protected from contamination while being stored, prepared, transported and served.
| All Laurel House, Inc Residential Sites will have bag clips and/or plastic food storage containers ordered for all cereals to be stored in. Storage containers and/or clips will be in the homes for any other food items that are in bags so they can be stored appropriately. |
11/26/2025
| Implemented |
| 6400.214(b) | At 9:48 AM on 10/3/25, neither hard nor electronic copies of the following regarding Individual #2's most current records were kept at the home: a current, dated photograph; the most current Service Plan; an applicable behavior support plan; and an applicable psychological evaluation. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Laurel House Inc Program Supervisor/Specialist updated the individuals' chart at the residential site with a current photo, HCSIS Individual Support Plan, Behavioral Support Plan, and psychological evaluation. |
10/17/2025
| Implemented |
| 6400.216(a) | At 9:48 AM on 10/3/25, located on the bottom right open, accessible shelf of the desk situated in the home's living room were the following of Individual #1's and Individual #2's unlocked records: a green binder, entitled, "Service Docs.," containing the daily service notes that revealed personal information, such as outcome goals regarding health, leisure, behavior, and hygiene; Master Client Index Numbers; and Master Provider Index Numbers. | An individual's records shall be kept locked when unattended.
| Training Records will be reviewed to ensure that all Laurel House Inc staff have taken the April 2025 assigned HIPPA Basics Training on Relias. Program Supervisors/Specialists will arrange for a HIPPA review during their November 2025 Staff Meetings at the Residential Sites.
Documentation attached for review |
11/26/2025
| Implemented |
| 6400.32(r)(1) | At 9:59 AM on 10/3/25, Individual #1's bedroom door was equipped with a lock, requiring a key to disengage it from the outside. However, agency interviews revealed that only staff, not Individual #1, are in possession of a key to unlock and lock Individual #1's bedroom door. At 10:02 AM, Individual #2's bedroom door was equipped with a lock, requiring a key to disengage it from the outside. However, agency interviews revealed that only staff, not Individual #2, are in possession of a key to unlock and lock Individual #2's bedroom door. [Repeated Violation-11/13/24, et al] | 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. | On 10/22/2025 individual 1 and Individual 2's door locks were replaced on their bedroom doors and keys were provided to both of them. Staff were also provided with the keys to unlock the bedroom doors in case of an emergency. |
10/22/2025
| Implemented |