| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.82(a) | REPEAT from 8/30/21 annual inspection: The written emergency evacuation plan states, in case of a fire all employees are evacuated across the road to the camco building using the established staff responsibilities for building evacuation as the staffing plan. However, the staff responsibilities are not included in the plan. | Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas. | In order to comply with 2390.82(a), additional clarification has been added to the evacuation policy stating what that staff are responsible for evacuating listed areas.
Document 1a |
08/31/2022
| Implemented |
| 2390.151(e)(8) | REPEAT from 8/30/21 annual inspection: Individual #1's current, 6/15/22 assessment does not include their ability to evacuate the facility. The assessment states "at this time Individual #1 hasn't participated in a fire drill at the facility yet but according to their ISP evacuated independently at home." As of 8/17/22, the individual hasn't had an assessment completed that assesses their ability to evacuate the facility. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | Ability to evacuate the building in the case of an emergency was assessed and documented in accordance with 2390.151(e)(8) in the annual assessment.
Document 2a |
09/30/2022
| Implemented |
| 2390.21(u) | Individual #1's individual rights reviewed with them on 5/25/22 did not include a review of their rights defined in 2380.21(a), (b), (d)-(f), and (s).
Individual #2's individual rights reviewed with them on 5/14/22 did not include a review of their rights defined in 2380.21(a), (b), (d)-(f), and (s). Additionally, the agency did not produce records that individual's rights were reviewed with the individual in 2021. | 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. | Client rights form has been updated to include 2390.21(a), (b), (d-f), and (s). This form will be distributed, reviewed, and signed by each client to come into compliance with the regulation.
Document 3a |
09/30/2022
| Implemented |