| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Direct Service Worker #4, date of hire 9/22/2025, did not have a Pennsylvania criminal history record check completed. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | On 05/01/2025, Direct Service Worker #4 did have a Pennsylvania criminal history record check (Control #R32971881) completed. The employee file has been updated to include the record. |
03/12/2026
| Implemented |
| 2380.53(a) | On 2/6/2026 at 3:34PM, multiple bottles of Windex, Easy-Off Oven Cleaner, Easy-Off Cleaner Degreaser, Kaboom, Pledge, and Spectracide Wasp and Hornet Killer were unlocked and accessible in the closet of the gymnasium on the first floor of the facility. At 3:40PM, Lysol Power Clinging Gel and Clorox Bleach were unlocked and accessible in the closet of the unisex bathroom near the gymnasium on the first floor of the facility. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All poisonous materials have been moved to locked, secure areas that are not accessible to individuals. |
03/11/2026
| Not Implemented |
| 2380.59(b) | On 2/6/2026 at 2:58PM, the hot water temperature measured 123.2F at the sink in the men's bathroom on the second floor of the facility. At 3:45PM, the hot water temperature measured 131.7F at the sink in the kitchen on the first floor of the facility. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The services of a licensed plumber have been engaged to bring the facility's water temperature below the 120°F threshold. |
03/18/2026
| Not Implemented |
| 2380.84 | The annual fire safety inspections were completed on 11/12/2024 and then again 1/27/2026. [Repeat Violation, 3/20/2025] | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | The next annual fire safety inspection will be conducted in a timely manner. The Compliance Manager has scheduled the upcoming inspection for October 2026. |
03/16/2026
| Not Implemented |
| 2380.86 | On 2/6/2026 at 3:29PM, a portable space heater was on a shelf in the closet of the lab room on the third floor of the facility. At 3:34PM, a portable space heater was on a table in the closet in the gym on the first floor of the facility. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices. | All (2) portable space heaters were removed from the facility upon discovery and will not be allowed on the premises. |
03/11/2026
| Not Implemented |
| 2380.111(c)(1) | Individual #1's physical examination, completed 9/5/2025, did not include a review of the individual's previous medical history. The physical examination form did not include a section for previous medical history and a medical history summary was not included as a supplemental attachment for review. Individual #4's physical examination, completed 4/17/2025, did not include a review of the individual's previous medical history. The physical examination form did not include a section for previous medical history and a medical history summary was not included as a supplemental attachment for review. | The physical examination shall include: A review of previous medical history. | Upon discovery, the individual record was immediately reviewed. The medical history section was completed by obtaining the necessary information, and/or the existing medical history summary was attached to the physical exam, ensuring documentation reflects that the individual's previous medical history was reviewed by the physician.
A review of all current physical exam records was conducted to ensure that medical history is documented within the physical exam or that a medical history summary is attached. Any missing or incomplete documentation was corrected accordingly. |
03/16/2026
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 9/5/2025, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical examination form was left blank. Individual #2's physical examination, completed 9/10/2025, did not address medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical examination was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Upon discovery, the individual's record was immediately reviewed. The physician was contacted to obtain the necessary emergency medical information, including diagnoses, allergies, current medications, and other pertinent details required for emergency care. The physical exam was updated accordingly, and documentation was placed in the individual's file.
A review of all current physical exam records was conducted to ensure that emergency medical information is completed and clearly documented. Any missing or incomplete sections were corrected by obtaining the necessary information and updating the record.
Staff responsible for coordinating and maintaining medical documentation were informed of the requirement to ensure that all sections of the physical exam are fully completed, including those related to emergency diagnosis and treatment information. |
03/16/2026
| Implemented |
| 2380.111(c)(11) | Individual #1's physical examination, completed 9/5/2025, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. The physical examination form only included a section titled "Physician Recommendations" and this section of the examination form was left blank. | The physical examination shall include: Special instructions for an individual's diet. | The individual's record was immediately reviewed, and the physician was contacted to obtain clarification and updated recommendations, including any health maintenance needs and required bloodwork intervals. The physical exam documentation was updated accordingly, and all information was placed in the individual's file.
A review of all current physical exam records was conducted to ensure that the "Physician Recommendations" section is completed and includes any ongoing health maintenance needs, including laboratory work when applicable. Any missing or incomplete documentation was obtained and corrected.
Staff responsible for coordinating and maintaining medical documentation were informed that all sections of the physical exam must be fully completed, including documentation of health maintenance needs and physician recommendations. |
03/16/2026
| Implemented |
| 2380.113(a) | Direct Service Worker #4, date of hire 9/22/2025, has not completed a physical examination. [Repeat Violation, 3/20/2025] | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | A full audit of all personnel records was conducted to identify non-compliant staff. Staff members who were missing physical examinations were immediately notified and scheduled for the required evaluations within 21 days.
Any staff without the required documentation were restricted from working with individuals until compliance was verified, in accordance with ODP health and safety expectations. Personnel records have been updated to reflect compliance. |
03/27/2026
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #4, date of hire 9/22/2025, has not completed Tuberculin skin testing by Mantoux Method. [Repeat Violation, 3/20/2025] | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | A full audit of all personnel records was conducted to identify non-compliant staff. Staff members who were missing TB screening were immediately notified and scheduled for the required evaluations within 14 days.
Any staff without the required documentation were restricted from working with individuals until compliance was verified, in accordance with ODP health and safety expectations. As of 2/23/2026, all personnel records have been updated to reflect full compliance. |
02/23/2026
| Implemented |
| 2380.132(10) | On 2/6/2026 at 3:45PM, a carton of eggs with a best by date of 12/20/2025 was on the shelf in the refrigerator in the kitchen on the first floor of the facility. | If the facility provides or arranges for meals for individuals, the following requirements apply: Food shall be protected from contamination while being stored, prepared, served and transported. Food shall be stored in sealed containers. | The item was removed from the refrigerator immediately upon discovery. All other stored items were checked for compliance. |
03/11/2026
| Not Implemented |
| 2380.172(b) | Individual #2's assessment, completed 10/1/2025, was initially signed by an unknown person and covered with whiteout. It was then signed by Director #6. | Entries in an individual¿s record shall be legible, dated and signed by the person making the entry. | Staff have been informed that the use of whiteout is not acceptable when making entries in an individual's record. The errant entry will be struck through, and the entrant's initials and date will be added. |
03/11/2026
| Not Implemented |
| 2380.173(1)(ii) | Individual #1's record did not include identifying marks. Individual #2's record did not include identifying marks. Individual #3's record did not include identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The record was immediately reviewed and updated to include identifying marks or "none noted" when applicable. All individual records were reviewed to ensure that the required personal information (height, weight, hair color, eye color, race, and identifying marks) was documented in accordance with 2380 regulations. |
03/11/2026
| Implemented |
| 2380.173(1)(iv) | Individual #2's record did not include religious affiliation Individual #3's record did not include religious affiliation. Individual #4's record did not include religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The record was reviewed and updated to reflect the individual's religious affiliation or documented as "none" or "not specified" when applicable. A review of all individual records was conducted to ensure the religious affiliation field is completed in accordance with regulatory requirements. |
03/12/2026
| Implemented |
| 2380.181(e)(1) | Individual #1's assessment, completed by Program Specialist #5 on 5/28/2025, did not include the preferences of the individual. This information was omitted entirely from the assessment form. Individual #4's assessment, completed by Program Specialist #6 on 6/10/2025, did not include the preferences of the individual. This information was omitted entirely from the assessment form. Individual #2's assessment, completed 10/1/2025, does not address the individual's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The individual record was immediately reviewed and updated to reflect the individual's preferences based on information obtained from the individual and/or their support team. A review of all initial assessments was conducted to ensure the client-preference section was completed for each individual. Any missing information was obtained and documented in the record. |
03/12/2026
| Not Implemented |
| 2380.181(e)(2) | Individual #1's assessment, completed by Program Specialist #5 on 5/28/2025, did not include the dislikes of the individual. Page 11 of the assessment form indicates for Individual #1's likes, dislikes, and interests to be described; however, Program Specialist #5 failed to describe Individual #1's dislikes. Individual #2's assessment, completed by Program Specialist #5 on 10/1/2025, does not address the likes, dislikes and interests of the individual, including vocational and employment interests. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | The record was immediately reviewed and updated to reflect the individual's dislikes based on information obtained from the individual and/or their support team. If no dislikes were identified, the section was documented as "None reported" rather than being left blank. A review of all initial assessments was conducted to ensure that the client dislikes section is completed for each individual served. Any missing information was obtained and documented accordingly |
03/12/2026
| Not Implemented |
| 2380.181(e)(10) | Individual #1's assessment, completed by Program Specialist #5 on 5/28/2025, did not include the individual's lifetime medical history. The assessment form indicated that a lifetime medical history was completed; however, the history was not attached to the assessment and provided to the plan team as part of the assessment document. Individual #4's assessment, completed by Program Specialist #6 on 6/10/2025, did not include the individual's lifetime medical history. Individual #4's assessment form stated, "Is a lifetime medical history on file?" which was answered "no." The assessment form then indicated "if not, please complete a medical history assessment immediately;" however, the agency did not complete a lifetime medical history as indicated by the instructions on the assessment document. | The assessment must include the following information: A lifetime medical history. | Upon discovery, the individual record was immediately reviewed, and the lifetime medical history was obtained and properly attached to the assessment to ensure the record accurately reflects the individual's medical history. A review of all individual records was conducted to verify that when a lifetime medical history is on file, the documentation is present within the individual's record. Any missing documentation was obtained and attached accordingly. |
03/13/2026
| Not Implemented |
| 2380.181(e)(12) | Individual #2's assessment, completed 10/1/2025, does not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. This section reads, "check ISP summary." | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment was reviewed and updated to include appropriate recommendations for training based on the individual's needs, preferences, and goals. If no specific recommendations were identified, the section was documented as "None at this time" rather than being left blank. A review of all current assessments was conducted to ensure that the recommendations for the specific areas of training section are completed for each individual served. Any missing information was obtained and documented accordingly. |
03/13/2026
| Not Implemented |
| 2380.181(e)(13)(vi) | Individual #2's assessment, completed 10/1/2025, does not include the individual's current level for community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | Upon discovery, the assessment was immediately reviewed and updated to reflect the individual's community integration needs, interests, and opportunities based on information obtained from the individual and/or their support team. If community integration needs were not identified at that time, the section was documented as "None at this time" rather than being left blank. A review of all current assessments was conducted to ensure that the community integration section is completed for each individual served. Any missing information was obtained and documented accordingly. |
03/13/2026
| Not Implemented |
| 2380.181(e)(14) | Individual #1's assessment, completed by Program Specialist #5 on 5/28/2025, did not include an assessment of the individual's knowledge of water safety, ability to swim, and ability to temper water. This information was omitted entirely from the assessment form. Individual #4's assessment, completed by Program Specialist #6 on 6/10/2025, did not include an assessment of the individual's knowledge of water safety, ability to swim, and ability to temper water. This information was omitted entirely from the assessment form. Individual #2's assessment, completed 10/1/2025, does not address the individual's knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | The assessment was immediately reviewed and updated to include documentation regarding the individual's water safety awareness and needs. This information was obtained from the individual and/or their support team to ensure the record accurately reflects the individual's abilities and safety considerations. A review of all current initial assessments was conducted to verify that water safety information is documented for each individual served. Any assessments missing this information were updated accordingly. |
03/11/2026
| Not Implemented |
| 2380.36(a) | Program Specialist #2, date of hire 1/29/2024, was not trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. Direct Service Worker #3, date of hire 1/5/2026, was reportedly trained in fire safety. However, the training date was not provided, and compliance could not be measured. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | The facility has identified and contacted a qualified fire safety expert with the Pittsburgh Fire Department, and an annual fire safety training curriculum will be developed.
All current program specialists and direct service workers will complete the required training.
Documentation of training completion, including date, content, trainer credentials, and staff signatures, will be maintained in personnel files. |
04/17/2026
| Implemented |
| 2380.36(b) | Direct Service Worker #4, date of hire 9/22/2025, was trained in fire safety on 9/23/2025. This training was not completed by a fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The facility has identified and contacted a qualified fire safety expert with the Pittsburgh Fire Department, and an annual fire safety training curriculum will be developed.
All current program specialists and direct service workers will complete the required training.
Documentation of training completion, including date, content, trainer credentials, and staff signatures, will be maintained in personnel files. |
04/17/2026
| Implemented |
| 2380.39(b)(1) | Chief Executive Officer #1, date of hire 1/29/2024, did not complete at least twelve hours of training during the annual training year, 2/1/2025 through 1/31/2026. | The following staff persons shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | All required annual trainings were:
Completed immediately upon identification or scheduled for completion within 21 days.
Documentation of completed training certificates will be placed in the CEO's personnel file. |
04/01/2026
| Implemented |
| 2380.39(c)(1) | Chief Executive Officer #1's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | All required annual trainings were:
Completed immediately upon identification or scheduled for completion within 21 days.
Documentation of completed training certificates will be placed in the CEO's personnel file. |
04/01/2026
| Implemented |
| 2380.39(c)(2) | Chief Executive Officer #1's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | All required annual trainings were:
Completed immediately upon identification or scheduled for completion within 21 days.
Documentation of completed training certificates will be placed in the CEO's personnel file. |
04/01/2026
| Implemented |
| 2380.39(c)(3) | Chief Executive Officer #1's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | All required annual trainings were:
Completed immediately upon identification or scheduled for completion within 21 days.
Documentation of completed training certificates will be placed in the CEO's personnel file. |
04/01/2026
| Implemented |
| 2380.39(c)(4) | Chief Executive Officer #1's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include recognizing and reporting incidents. Program Specialist #2's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | All required annual trainings were:
Completed immediately upon identification or scheduled for completion within 21 days.
Documentation of completed training certificates will be placed in the appropriate personnel file. |
04/01/2026
| Implemented |
| 2380.39(c)(5) | Program Specialist #2's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | The Program Specialist will complete the remaining required safe and appropriate use of behavior supports training, and the Staff Training Records will be updated to reflect completion.
The Program Specialist or Training Coordinator has verified completion and documented compliance. |
03/31/2026
| Implemented |
| 2380.39(c)(6) | Program Specialist #2's trainings during the annual training year, 2/1/2025 through 1/31/2026, did not include the implementation of the individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The Program Specialist will complete the required implementation of the individual plan training, and the Staff Training Records will be updated to reflect completion.
The Program Specialist or Training Coordinator has verified completion and documented compliance. |
03/31/2026
| Implemented |
| 2380.123(a) | Individual #5 is prescribed Methylphenidate 20MG. This prescription was filled on 5/13/2025 with a quantity of thirty tablets described on the label as, "yellow, round-shaped Tablet imprinted with S on the front and 2.0 on the back." On 2/6/2026 at 3:09PM, there were eighty-two pills in the medication bottle. Some of the tablets were yellow and some were orange without the S inscription. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by pharmacy. | The matter was discussed with the parent (mother) on 02/09/2026, and the medication (Methylphenidate, 20MG) that was prescribed to the Individual was returned to the parent (mother) on 02/10/2026. The parent was advised that the medication in its current form could not be administered to the individual while in programming. |
02/10/2026
| Not Implemented |
| 2380.123(d) | On 2/6/2026 at 2:55PM, a bottle of GNC Immune Defense Gummies was unlocked and accessible in a locker in the Life Skills program room on the third floor of the facility. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Upon discovery, the over-the-counter vitamins were removed and discarded. Such items are no longer allowed in the facility. |
03/11/2026
| Not Implemented |
| 2380.125(e) | Individual #5 is prescribed Methylphenidate 20MG with instructions to, "take one tablet by mouth every day at 3PM." Individual #5's first name and "12:30" was hand-written onto the medication label with black marker. This medication has been administered to Individual #5 at 12:30PM while attending day program. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | The matter was discussed with the parent (mother) on 02/09/2026, and the medication (Methylphenidate, 20MG) that was prescribed to the Individual was returned to the parent (mother) on 02/10/2026. The parent was advised that the medication in its current form could not be administered to the individual while in programming. |
02/10/2026
| Not Implemented |
| 2380.126(a)(13) | Program Specialist #6 administered medications to Individual #4 and did not sign their full name on the individual's Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Upon discovery, Program Specialist #6 no longer administered medication to individuals. The Medication Administration record bears the name of the nurse. |
03/11/2026
| Not Implemented |
| 2380.129(a) | Program Specialist #6 administered medications to Individual #4 and Individual #6. Program Specialist #6's most recent training in medication administration was completed via the online Modified Medication Administration Training Course on 7/28/2024. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Upon discovery, Program Specialist #6 no longer administered medication to individuals. The Medication Administration record bears the name of the nurse. |
03/11/2026
| Not Implemented |
| 2380.173(5) | The invitation for Individual #2's most recent service plan meeting was not in the individual's record. The invitation for Individual #3's most recent service plan meeting was not in the individual's record. | Individual plan documents as required by this chapter. | The record was immediately reviewed, and the ISP invite letter was obtained and placed in the individual's file to ensure documentation reflects that all required parties were properly notified of the ISP meeting.
A review of all individual records was conducted to verify that ISP invitation letters are present and filed appropriately. Any missing documentation was obtained and added to the record. |
03/16/2026
| Implemented |
| 2380.173(6) | Individual #1's record did not include a copy of the individual's psychological evaluation. Individual #1's support plan, last updated 10/29/2025, indicated that a psychological evaluation was completed on 8/26/2014; however, the agency did not provide documentation to demonstrate their attempts to obtain a copy of this evaluation. Individual #4's record did not include a copy of the individual's psychological evaluation. The agency did not provide documentation to demonstrate their attempts to obtain a copy an evaluation. | Copies of psychological evaluations, if applicable. | The record was immediately reviewed to determine applicability. When applicable, the psychological evaluation was obtained and placed in the individual's file. If not applicable, the record was updated to clearly reflect "Not applicable" to ensure the section is not left blank. A review of all individual records was conducted to verify that psychological evaluations are present when applicable and properly filed. Any missing documentation was obtained and added to the record, or documentation was updated to indicate non-applicability. |
03/16/2026
| Not Implemented |
| 2380.181(f) | Program Specialist #6 did not provide Individual #4's assessment, completed 6/10/2025 to the individual plan team members at least 30 calendar days prior to the annual plan team meeting that occurred on 12/11/2025. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Upon discovery, the record was reviewed and documentation was obtained, where available, to verify that the assessment was shared with team members. When documentation could not be located, a late distribution was completed and documented accordingly.
A review of all upcoming and recently completed ISP records was conducted to ensure that assessments are sent to the team at least 30 days before the ISP meeting and that proof of distribution (e.g., email, fax confirmation, or signed acknowledgement) is maintained in the individual's file. |
03/12/2026
| Implemented |
| 2380.182(c) | Individual #4's assessment, completed by Program Specialist #6 on 6/10/2025, stated that the "Consumer is rarely able to safely use and avoid poisonous materials with significant supervision and support;" however, Individual #4's support plan, last updated 12/12/2025, stated "[Individual #4] does not touch poisonous substances once [they are] informed about them. [They] would not ingest poisonous substances if unattended." The individual plan has not been revised based upon the current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Upon discovery, the individual's record was immediately reviewed. The assessment and ISP were reconciled to ensure consistency, and updates were made to accurately reflect the individual's current abilities and support needs based on team input and the most recent information. All changes were documented accordingly.
A review of all individual records was conducted to ensure that assessments and ISPs are consistent and reflect current information. Any discrepancies identified were corrected.
Staff responsible for completing assessments and ISP documentation were informed of the requirement to ensure consistency between all documents and to update the ISP whenever there are changes in the individual's abilities, needs, or risk factors. |
03/16/2026
| Implemented |