| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The license for this chapter expired on 10/1/2019. The self-assessment for this residence was not completed until 9/10/2019. | 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.
| The Residential Services Administrator reviewed with all Program Specialist the completion of self assessment no later than July prior to the license expiration and completion no earlier than April prior to the expiration of the license. |
10/08/2019
| Implemented |
| 6400.72(b) | The screen was torn on the side door to this residence. | Screens, windows and doors shall be in good repair. | Screen will be repaired and monthly inspection of the screens will be performed. Facility repair request will be completed for any screens that are not in good repair. |
10/14/2019
| Implemented |
| 6400.112(f) | The front door was the only exit utilized during fire drill for the past year. | Alternate exit routes shall be used during fire drills. | Program Specialist and employees at this location have been informed that alternating exits need to be used during fire drills. Program Specialist will review fire drill logs to ensure that alternating are utilized. |
11/01/2019
| Implemented |
| 6400.113(a) | Individual #3 had fire safety training on 8/3/2018. He didn't have fire safety training again until 9/26/2019, which exceeds the annual requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Program Specialist will ensure that fire safety training is conducted at least 2 times per year in order to ensure that fire safety is conducting as required by regulation. |
10/11/2019
| Implemented |
| 6400.181(e)(12) | This section was blank throughout Individual #3's assessment dated 7/3/2019. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist will review all assessments to ensure that recommendations for specialist areas of training and programming and services are completed. In addition, agency will be instituting electronic record keeping and this area will be a required field on the assessment which will ensure it is not missed. |
11/08/2019
| Implemented |