| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | The surface of the siding on the rear of the home was covered in small dark spots that appeared to be mold. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The home's siding was power washed and cleaned. |
08/14/2025
| Implemented |
| 6400.112(c) | The fire drill completed on 9/12/24 and 10/10/24 did not indicate that the smoke detectors were operative at the time of the drill. Yes or no were not circled in the "Was it operative" section.
The 11/20/24 drill documentation noted that the system was not operative and that there was no bed shaker or strobe in the home. There was no additional notation to indicate that the alarm was not functional, no issues were indicated on the form. A bed shaker was in use at the home and operative at the time of inspection. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Fire Drill form was updated to indicate that smoke detectors are interconnected, BOLD responses, and the word operative was changed to working. Information was added to the form advising managers to email facilities if not working and to enter a repair order in the system. |
08/20/2025
| Implemented |
| 6400.165(g) | Individual #1 had a three-month medication review completed in July 2025. The dose of the medication was not included on the appointment form. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Residential Managers will review the PVR to ensure the prescribing provider has completed the form and recorded the reasons for prescribing the medication, need to continue and the dosages at the time of the appointment. |
08/09/2025
| Implemented |