| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | The windows of both bathrooms were very hard to open and close. The window in Individual Two's bedroom was very hard to open. | Screens, windows and doors shall be in good repair. | Program leadership submitted maintenance requests to Merakey's facilities Department the week of the audit to fix the window throughout the home to ensure they can all open and close. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.105 | There were chemical cleaning solutions stored in a cabinet in a room where the hot water heater and furnace/boiler were located and the room was hot. Most of the cleaning solutions' labels state to store in a cool and dry place. Also brooms mops and a water pale were stored up against the furnace. The cleaning solutions were moved to another locked location during the inspection, and the items were moved away from the furnace/boiler. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| As noted in the deficiency, the chemical solutions were removed from near the water heater and placed in a different location upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.110(a) | The attic smoke detector was inoperable. | 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 week of the audit to fix the inoperable smoke detector. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.216(a) | The behavioral Support Plan for Individual One was in a binder that was unlocked. this was locked up during the time of inspection. | An individual's records shall be kept locked when unattended.
| As noted in the deficiency, the BSP binders were locked at the time of inspection. |
04/30/2026
| Implemented |