| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drills conducted on 12/16/2024, 1/13/2025, 2/7/2025, 3/16/2025, 4/15/2025, 5/22/2025, 6/14/2025, 7/7/2025, 8/15/2025, 9/14/2025 did not include problems encountered. The agency's form to record fire drills did not include a space for staff to document problems encountered during fire drills. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Fire Drill Template form was updated by the chief operating officer on 11/10/25 to include a blank section for DSPs to describe any problems encountered that are not captured by the questions on the previous version of the document. |
11/10/2025
| Implemented |
| 6400.46(b) | Program Specialist #1 participated in training to include general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place(s), smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered on 3/18/2024 and again on 3/20/2025. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The program specialist has retaken the training related to general fire safety and is currently in compliance with the requirement to complete annually (3/20/25 and 10/05/25) |
11/11/2025
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Promethazine Sol DM with instructions to "take 5mL by mouth every four hours as needed for cough." Neither the medication label issued by the pharmacy nor the October 2025 medication administration record indicated the strength of the prescribed medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | PDC pharmacy created a method using their software to include a line indicating strength of the medication since it does not come from the manufacturer with a strength listed. |
11/03/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed by Program Specialist #1 on 7/24/2025, indicated "No" the individual is not able to temper water for handwashing and bathing while their Individual Support Plan, last updated 10/14/2025, stated "[Individual #1] is able to adjust water temperature to shower and wash [their] hands independently." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program Specialist who marked the incorrect answer on the annual assessment observed the individual temper water to ensure this skill was still able to be completed independently. The assessment has been corrected and a new letter was sent to the SC noting an update to the temper water question to eliminate the discrepancy between the assessment and the ISP. |
10/29/2025
| Implemented |