| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | Dryer lint debris was observed adhering to an interior wall from a small hole that was observed in the residence's dryer exhaust vent to the home's exterior. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the dryer exhaust vent. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.72(a) | Two window screens were observed missing from the staff office, three from an individual's room, and two from another individual's room. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the missing window screens throughout the home. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.81(k)(6) | A mirror was not observed in an individual's bedroom. A picture of a mirror in a bedroom was sent to the agency's escort during the inspection. | In bedrooms, each individual shall have the following: A mirror. | The team emailed Individual one Support Coordinator on 3/31/2026 requested for a critical revision to be made to his ISP to include his refusal of having a mirror not being placed in their bedroom. The ISP will be updated to reflect those updates and redistributed to the team. |
04/30/2026
| Implemented |
| 6400.106 | 2025 Furnace inspection was not provided for the home. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Director of Programs is actively collaborating with Merakey's real estate team and safety team to have the furnaces at each cited home reinspected as soon as possible. Copies of each inspection will be maintained in the Fire Safety Binder by the Director of Programs. |
04/30/2026
| Implemented |
| 6400.110(a) | The third-floor bedroom occupied by an individual had a fire extinguisher that did not meet the minimum 2-a rating for each floor of a residence. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Program leadership submitted a maintenance request to Merakey's facilities Department the day of the audit to have a 2-a rating fire extinguisher for each floor. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26 |
04/30/2026
| Implemented |
| 6400.151(a) | Documentation verifying required physical examination was not provided for staff one. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff one's TB was completed on 2/17/25 and the physical was completed on 7/27/25. Results were signed off on by a physician. Please see attached. |
04/30/2026
| Implemented |