| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Self-Assessment was completed on 2/20/23. The time frame for the self-assessment to be completed was from 11/1/22 to 2/3/23. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Due to lack of knowledge of the regulation, assessors did not take into account both month and day when completing self-assessments. They were trained on 6400.15(a) on 5/17/2023. Attachment #1. |
05/24/2023
| Implemented |
| 6400.103 | (Repeat from 5/3/22) The written evacuation procedure developed did not identify the means of transportation or emergency shelter that would be used in the event of an emergency evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Program Specialist misunderstood the regulation. New Evacuation procedures were written to include all required information. Individuals and staff of the home were trained on the evacuation procedures as of 5/17/2023. Attachment #31. |
05/17/2023
| Implemented |
| 6400.104 | The letter sent to the fire department on 10/1/22 did not clearly identify the location of the individual's bedroom. | 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.
| Program Specialist error. The letter for this home was updated to include all correct information and sent to the local fire department on 5/3/2023. Attachment #32. |
05/17/2023
| Implemented |