| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | A fire drill shall be held during sleeping hours at least every six months. A fire drill was held during sleeping hours on 6/26/2025, then not again until 1/23/2026. | A fire drill shall be held during sleeping hours at least every 6 months. | The agency identified that the sleeping hours fire drill was not conducted within the required 6-month timeframe, this occurred due to tracking by calendar year rather than a rolling 6- month schedule. A sleeping hour fire drill was completed on 1/12/2026, the agency updated its tracking process and reviewed the requirement with responsible staff, |
02/28/2026
| Implemented |
| 6400.141(c)(11) | Individual #1's current physical examination completed on 4/14/2025 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for bloodwork at regular intervals. The area on the physical examination form for this information was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The agency reviewed Individual #1's physical examination dated 4/14/2025 and confirmed that the section addressing the individual's health maintenance needs, medication regimen, and need for bloodwork at recommended intervals was left blank. The agency contacted the PCP to obtain a corrected physical examination addendum that includes all required information. Once received, the updated documentation will be placed in the individual's record. |
03/02/2026
| Implemented |
| 6400.141(c)(15) | Individual #1's current physical examination completed on 4/14/2025 did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The agency reviewed Individual #1's physical examination dated 4/14/2025 and confirmed that the section for special instructions for the individual's diet was left blank. The agency contacted the PCP to obtain a corrected physical examination addendum that includes the required dietary instructions. The corrected documentation has been placed in the individual's record. |
03/02/2026
| Implemented |
| 6400.181(a) | Each individual shall have an updated annual assessment. The current annual assessment dated and signed by the program specialist on 9/27/2025 for Individual #1 was available in the Individual's program record, but the assessment contained multiple areas where the individual's name was not correct (self-administration of medications, water safety and financial management) making it unclear whether the information contained in the assessment applied to Individual #1 or a different individual. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The agency reviewed Individual #1's annual assessment dated 9/27/2025 and confirmed that several sections contained an incorrect individual name, making it unclear whether the information applied to Individual #1. The Program Specialist will complete and sign a corrected annual assessment specific to Individual #1 and place it in the record. Going forward, all annual assessments will be reviewed prior to filing to ensure the correct individual's name appears throughout and that all information is accurate and specific to the individual served. The Program Specialist/Designee will complete the review, and the Residential Director will monitor compliance through periodic record audits. |
02/25/2026
| Implemented |
| 6400.165(g) | Psychiatric medication reviews by a licensed physician must include documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The psychiatric medication reviews for Individual #1 that occurred on 6/24/2025, 9/22/2025 and 12/15/2025 did not
include documentation of the medications prescribed for the individual or the necessary dosages. | 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. | The agency has reviewed the psychiatric medication reviews forms for Individual #1 dated 6/24/2025, 9/22/2025, and 12/15/2025 and confirmed that the documentation did not include the prescribed medications and necessary dosages. The psychiatric prescriber was contacted and has provided amended documentation that includes the reason for prescribing each medication, the need to continue the medication, and the necessary dosage. The corrected documentation will be placed in the individual's record. |
03/05/2026
| Implemented |