| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The light outside the front exit door is inoperable. There is not another source of light in that area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The porch light was replaced and the circuit box was fixed, ensuring that outside lighting is operable. |
03/01/2023
| Implemented |
| 6400.82(e) | The bathtub in the bathroom on the first floor of the home did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | A non slip Matt was added to the bathtub. |
02/28/2023
| Implemented |
| 6400.101 | There is a turn lock on the basement side of the door between the basement and the garage posing an obstructed egress from the garage when engaged. There is not a ''man door" inside the garage. There is a padlock on the door leading to the staff office in the basement of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The padlock has been removed from the door leading to the staff office in the basement of the home. In addition, the turn lock on the basement side of the door between the basement and the garage has been removed. |
03/03/2023
| Implemented |
| 6400.110(b) | The closest smoke detector to Individual #1's bedroom is 16 feet away. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | In operable smoke detector has been installed within 15 feet of the individual's bedroom. |
02/16/2023
| Implemented |
| 6400.214(b) | Individual #1's most recent physical examination was not at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The individuals updated physical was placed at the home, to be included with the individual's entire file. |
02/27/2023
| Implemented |
| 6400.46(d) | Direct Service Worker #1's first aid and CPR training, completed on 5/29/2022, did not include an in-person component. Direct Service Worker #2's first aid and CPR training, completed 6/27/2022, did not include an in-person component. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The direct service worker #1 and #2 both have retaken the CPR and first aid course, with an in-person course. Documentation has been placed into the staff training file. |
02/23/2023
| Implemented |