| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | There was documentation provided that reflects a sleep fire drill was not conducted. The fire drills that were reviewed for the past year were all during awake hours. There should be a sleep drill every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | DSN has scheduled and completed a fire drill during sleeping hours on January 14, 2026, to immediately correct the lapse. Staff responsible for safety and emergency preparedness have been notified of the requirement for semiannual sleeping hour fire drills. |
01/14/2026
| Implemented |
| 6400.112(f) | The fire drill records reflect that all fire drills utilized the front door as their exit. The regulation states that alternate exits should be utilized. | Alternate exit routes shall be used during fire drills. | Effective immediately, all scheduled fire drills will incorporate the use of alternate exit routes in accordance with regulatory requirements. The next scheduled fire drill will utilize a different designated exit- side exit to ensure staff and individuals are familiar with all available egress options. |
01/14/2026
| Implemented |
| 6400.165(g) | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review every 3 months that includes the reason for prescribing the medication, the need to continue and the necessary dosage. The med review dated 8.21.25, 10.8.25, 10.27.25, and 12.8.25 did not include the current medications or the dosage. The form stated "see attached" however nothing was attached. | 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 provider has been notified about the missing medication lists and dosages for the affected reviews. The missing medication list and dosages has been added to the individual's record. The clinical team has reviewed the corrected documentation to ensure accuracy and completeness. |
01/14/2026
| Implemented |