| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | A large outside trashcan did not have a lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to obtain a new trash can with a lid. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.72(b) | The doorknob on the 1st floor utility closet was broken, and the inside knob was detached and stored in the basket inside the door. | 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 broken doorknob on the utility closet. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.105 | The 1st floor utility closet was being used to capacity to store various cleaning products and buckets, a small refrigerator, boxes, and a filing cabinet. The filing cabinet was being stored against the hot water heater. This was corrected at the time of the visit. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| As noted in the deficiency, the filing cabinet storing cleaning supplies was removed from near the water heater upon discovery during the audit. |
04/30/2026
| Implemented |
| 6400.32(h) | Individual One's bedroom is "loft style" and does not have a door or curtain for privacy. the recommendation was given to have a Team meeting with the individual so she can express her wants and needs around privacy in their bedroom, and to have this documented in the ISP. | An individual has the right to privacy of person and possessions. | Program leadership submitted a maintenance request to Merakey's facilities Department the week of the audit to add window coverings to the two windows. The Facilities team expects all outstanding maintenance requests to be completed by 4/30/26. |
04/30/2026
| Implemented |
| 6400.46(b) | Generic Fire Safety Training was completed for staff one; however, required site-specific training related to evacuation procedures and designated meeting locations specific to the home's design and layout was not completed. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff one completed their annual required site-specific training related to evacuation procedures
and designated meeting locations specific to the home's design and layout on 2/26/2026. Attached is a copy of the training roster. |
04/30/2026
| Implemented |
| 6400.46(b) | The staff on site at the time of the visit stated they had just transferred to the home and did not know how the fire system worked. Subsequently, the accompanying Program Specialist assisted with setting off the alarm. Documentation on site-specific Fire Safety Training for all staff working in the home was requested and not received. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff one completed their annual required site-specific training related to evacuation procedures
and designated meeting locations specific to the home's design and layout on 3/17/2026. Attached is a copy of the training roster. |
04/30/2026
| Implemented |