| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(e) | The master shower was not equipped with a non-slip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | We replaced the non-skid mat in the tub. We audited all homes to ensure showers and tubs were equipped with non-skid surfaces. |
10/09/2026
| Implemented |
| 6400.112(e) | Drills were held during overnight hours on 09/21/26 & 03/23/26 which exceeds the regulatory requirement of at least one overnight drill every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Managers were retrained on expectations of drills and documentation |
10/09/2025
| Implemented |
| 6400.181(e)(10) | The Lifetime Medical History for Individual #1 was not complete. | The assessment must include the following information: A lifetime medical history. | Lifetime Medical History for Individual #1 was updated and completed. The provider transitioned to using therap for all assessments, including the lifetime medical history in the document. |
10/09/2026
| Implemented |
| 6400.181(f) | Records for Individual #1 did not include documentation of the individual assessment being shared with plan team members at least 30 days prior to the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialist was retrained on timeframes for sharing completed assessments. The provider will use the distribution log within Therap to document that assessments were provided at least 30 calendar days prior to the ISP Plan Meeting |
10/09/2026
| Implemented |