| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration of the agency's certificate of compliance. The certificate of compliance expired on 8/15/2022 and the self-assessment was completed on September 7, 2022. | 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 Supervisor will complete each homes self-assessment within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The Residential Supervisor will submit the correct self-assessment to licensing upon request. |
04/30/2023
| Implemented |
| 6400.112(b) | The fire drill completed on 10/14/2022 was not held during normal staffing conditions. Normal staffing conditions include 3 staff during waking hours and 2 staff during overnight hours. The fire drill completed on 10/14/2022 included 4 staff. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | Program Specialist Supervisors will continue to train individuals and staff on fire drill regulations, including normal staffing conditions during fire drills. |
12/21/2022
| Implemented |
| 6400.46(b) | Staff #1 was not trained annually by a fire safety expert. Staff #1 received fire safety training on 12/14/2020, then not again until 1/02/2022. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Training records for all staff will be reviewed by supervisors to ensure all training requirements are met. Supervisors train staff on tracking their trainings to ensure they are meeting deadlines. |
12/14/2022
| Implemented |