| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.21(u) | The Client Rights forms for Individuals #3 and #4 did not include a complete list of rights as outlined in the regulations. | The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter. | Statement of Individual rights has been revised on 8/26/26, see attachment #40 and sent for all individuals to review and sign off. This was updated and reviewed with Individuals #3 and #4 on 9/1/26. See attachments #11, 11a, 12, 12a. |
09/17/2026
| Implemented |
| 2390.151(f) | Records for Individual #1 did not include documentation that the annual Assessment was sent to plan team members at least 30 days prior to the ISP Meeting.
The annual Assessment for Individual #2 was not sent to plan team members prior to the ISP Meeting. The Assessment is required to be shared at least 30 days prior to the plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | All Program Specialists will receive training on 9/17/26 to ensure compliance that assessments are sent to all team members at least 32 days prior to annual meeting. this will be attachment #14
PS's attended a meeting on 9/17/26 and review the timeline of assessments. The chart review forms will be reviewed see attachment #2. |
09/17/2026
| Implemented |
| 2390.153(c) | Records for Individual #1 did not include a list of individuals that participated in the 05/01/2025 and 05/21/2026 ISP Meetings. | The list of persons who participated in the individual plan meeting shall be kept. | A copy of the sign in sheet for 5/21/26 meeting for Individaul #1 was received by the SC and is attachment 15, 15a, 15b
Chart review form attachment #2 includes the requirement of the sign off sheet, that PS's will request prior to the end of the annual meeting. |
09/17/2026
| Implemented |
| 2390.195(a)(4) | Individual #5 is prescribed PRN Motrin. The medication was available; however, it was not listed on the MAR. This was corrected at the time of inspection. | A medication record shall be kept, including the following for each client for whom a prescription medication is administered: Name of medication. | All medications will be listed on a medication record. This was corrected at time of inspection. This information has been added to the site safety checklist see attachment #16. All Directors will receive training regarding medications being listed on MARS on 9/16/26. |
09/16/2026
| Implemented |