| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(h) | There were two windows located in individual #1's bedroom that had a frosted film covering that did not provide a view of the outside. The window located on the side of the house measured 30 inches high by 7 feet long. The window facing the front of the home was 24 inches high by 7 feet long. | Each bedroom shall have at least one exterior window that permits a view of the outside. | 01/30/2025, Building and Grounds staff removed portion of film covering on bedroom windows allowing view of outside.
NOTE: Film was installed as a house specific strategy to ensure privacy due to Individual's ISP requirement that bedroom window does not have blinds due to destructive behavior |
02/03/2025
| Implemented |
| 6400.106 | The furnace was inspected and cleaned by a professional furnace cleaning company on 9/9/23, and then again on 11/4/24. This exceeds the annual requirement. | 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.
| By 02/28/2025, Buildings and Grounds Facility Manager will create and implement a common due date tracking Outlook Calendar that is accessible to Buildings and Grounds staff to ensure furnace inspections and cleanings are scheduled for completion 330 days from the last inspection date. |
02/28/2025
| Implemented |
| 6400.111(e) | The fire extinguisher on first floor was locked in cabinet located under the sink in the kitchen and unable to be readily available in case of an emergency. | A fire extinguisher shall be accessible to staff persons and individuals. | 01/30/2025, fire extinguisher was taken out of locked cabinet and placed on the cabinet to be readily available in the case of emergency.
By 02/28/2025, House Supervisor and staff will be retrained on 6400.111(a)-6400.111(f). Training shall be documented. |
01/30/2025
| Implemented |
| 6400.166(b) | Individual #1's prescription medication Melatonin 3MG tab (1) Take 1 tablet by mouth at bedtime (9:30PM) was not initialed as administered on 1/3, 1/5, 1/6, 1/8, 1/9, 1/11, 1/21, 1/22, 1/22, 1/23, 1/24, 1/27, and 1/28, as indicated by Individual #1's January 2025 Medication Administration Record (MAR). These sections of the MAR were blank. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | By 02/28/2025, House Supervisor and staff will be retrained on 6400.166(a)-6400.166(d). Training shall be documented in Relias.
By 03/07/2025, disciplinary action will be administered for staff person(s). |
02/10/2025
| Implemented |