| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | (Repeat 4/29/24) The provider opened this home with a self-inspection tool on 1/24/25. With the opening of each home, the provider is required to submit a completed self-inspection tool to ensure that all regulations are met. Staff #1 completed the self-inspection tool for the home documenting there were no violations. This was not accurate as there were violations found at the home. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | A ramp for the 2nd exit of the home was purchased on 5/8/2025, see Attachment #50 for the bill of sale. Once the ramp arrives and has been installed a picture will be sent as Attachment #51. The Residential Program will be restructured. There is no longer a Residential Director. The Program will be hiring a Residential Manager and another Residential Program Specialist. In the interim, the Director of Quality Assurance is working closely with the Residential Program Specialist and the Residential Coordinators to ensure consistency and compliance with the program until changes are made. The CEO, Residential Program Specialist, and Residential Coordinator will be trained on Regulation 6400.43(b)(1) no later than 5/31/2025 by the Director of Quality Assurance and will be sent as Attachment #52. |
05/31/2025
| Implemented |
| 6400.61(a) | Per individual #1's ISP, they cannot propel their own wheelchair, ambulate or get into their wheelchair on their own. During the inspection of the home on 4/22/25, the home was observed to have 2 exits. The second exit of the home, located through the office, has three steps leading to an outside patio area. Due to individual's mobility limitations, this exit is not accessible to them. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | A ramp has been ordered and will be installed once it arrives, see Attachment #50 for the bill of sale. A picture of the completed work will be sent as Attachment #51. The Residential Program Specialist and Residential Coordinator will be trained on Regulation 6400.61(a) no later than 5/31/2025 by the Director of Quality Assurance and will be sent as Attachment #53. |
05/31/2025
| Implemented |
| 6400.101 | During the walk through of the home on 4/22/25, it was observed that the side exit is located in the staff office which is kept locked. Having the door locked and needing a key to unlock the exit causes the exit to be obstructed. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The lock has been removed from the office for the side exit to be accessible, pictures sent as Attachment #54. |
05/31/2025
| Implemented |