| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The notification to the fire department does not include the total capacity and general mobility needs of individuals in the home. Various documents were presented and reviewed that included conflicting information. | 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.
| A updated letter was completed by the Residential Director and sent to the fire department which includes information on the location of the bedrooms, and the number of individuals who require assistance with evacuation.
Copy attached.
Completed 12/17/25
Completed 12/17/25 |
12/18/2025
| Implemented |
| 6400.112(a) | Fire drills are not unannounced. There was a calendar in the living room of the home accessible to both staff and individuals with the date of when the December fire drill was to take place. | An unannounced fire drill shall be held at least once a month. | An unannounced fire drill was run on 12/19/25.
Copy attached.
Completed 12/19/25 |
12/22/2025
| Implemented |
| 6400.112(g) | Fire drills are not held at different times of the day/night. Sleep fire drills were held on 12/29/24 at 6:29am, 3/20/25 at 5:30am, 6/25/25 at 5:10am and 9/11/25 at 5:00am. These fire drills were all within less than an hour of each other. | Fire drills shall be held on different days of the week and at different times of the day and night. | The Residential Director retrained all staff on fire drill procedures including requirements to be held on different days of the week, different times of the day, using different exits, and the requirement that fire drills are unannounced.
Copy attached.
Completed 12/22/25
Completed 12/22/25 |
12/22/2025
| Implemented |
| 6400.193(a) | At the time of inspection all sharps were locked in the home despite there being only one individual in the home with a restrictive procedure plan in place with regard to sharp safety. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | The Program Specialist emailed the Supports Coordinator on 12/19/25 to request that the ISP for individuals T.C. be updated to reflect that he lives in a home where sharps are locked due to a RPP and that he has independent access via a thumbprint lock.
Copy attached.
Complete 12/19/25
The Behavior Specialist emailed the Supports Coordinator on 12/19/25 with a copy of N.B.'s RPP for sharps and request to ensure ISP reflects RPP.
Copy attached.
Complete 12/19/25
The Program Specialist reviewed the assessment for individual B.H. to determine if he should have independent access and emailed the Supports Coordinator with requested changes to document access to sharps.
Copy attached.
Completed 1/13/2 |
03/11/2026
| Implemented |