| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(a) | The main program building did not have hot water under pressure in the bathroom and kitchen areas. The hot water temperature was measured at 70.8 degrees Fahrenheit in the bathroom at the time of the inspection. | The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas. | THE PLUMBING COMPANY WAS CONTACTED AND IT WAS DETERMINED THAT THE HOT WATER HEATER WAS LEFT UNPLUGGED IN ERROR AFTER THEIR SCHEDULED MAINTENANCE SERVICE. |
07/02/2025
| Implemented |
| 2380.84 | There was no documentation that an annual onsite fire safety inspection was conducted by a fire safety expert. | The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | THE ANNUAL FIRE SAFETY INSPECTION COMPANY WAS CONTACTED TO UPDATE THE REPORT TO INCLUDE ALL THE NECCESSARY COMPONENTS. |
07/02/2025
| Implemented |
| 2380.87(b) | Individual #2 is hearing impaired and requires hearing aids and a bed shaker device to alert them in case of fire, according to their current Individual Support Plan (ISP). The fire alarm system in the facility is not equipped so that the individual would be alerted in the event of a fire if unable to hear the alarm. | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. | THE ELECTRICIAN WAS CONTACTED FOR INSTALLATION OF STROBE LIGHTS THROUGHOUT THE FACILITY. |
07/02/2025
| Implemented |
| 2380.91(a) | Individual #1 had fire safety training initially on 1/08/2024 and again on 1/07/2025, but both fire safety trainings occurred out in the community when the individual was receiving community participation services only from the provider. The individual has not received fire safety training since beginning to attend the facility-based 2380 program, with training specific to the facility such as evacuation procedures and the designated meeting place.
Individual #2 had initial fire safety training on 2/18/2025 but was only receiving community participation services only from the provider. The individual has not received fire safety training since beginning to attend the facility-based 2380 program, with training specific to the facility such as evacuation procedures and the designated meeting place. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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, and smoking safety procedures if individuals smoke at the facility. | INDIVIDUAL #1 AND INDIVIDUAL #2 HAVE COMPLETED FIRE SAFETY |
07/01/2025
| Implemented |
| 2380.111(c)(8) | The initial physical examination completed on 5/22/2025 did not include the following (area on the form was blank): Physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | THE MANAGING DIRECTOR HAS REQUESTED THE MEDICAL PROVIDER TO COMPLETE THE PCAS PHYSICAL FORM IN ITS ENTIRETY. INSTRUCTIONS HAVE BEEN SENT AS WELL. |
07/01/2025
| Implemented |
| 2380.111(c)(9) | The initial physical examination completed on 5/22/2025 did not include the following (area on the form was blank): Allergies or contraindicated medication. | The physical examination shall include: Allergies or contraindicated medication. | THE MANAGING DIRECTOR HAS REQUESTED THE MEDICAL PROVIDER TO COMPLETE THE PCAS PHYSICAL FORM IN ITS ENTIRETY. INSTRUCTIONS HAVE BEEN SENT AS WELL. |
07/01/2025
| Implemented |
| 2380.111(c)(10) | The initial physical examination completed on 5/22/2025 did not include the following (area on the form was blank): Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | THE MANAGING DIRECTOR HAS REQUESTED THE MEDICAL PROVIDER TO COMPLETE THE PCAS PHYSICAL FORM IN ITS ENTIRETY. INSTRUCTIONS HAVE BEEN SENT AS WELL. |
07/01/2025
| Implemented |
| 2380.111(c)(11) | The initial physical examination completed on 5/22/2025 did not include the following (area on the form was blank): Special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual's diet. | THE MANAGING DIRECTOR HAS REQUESTED THE MEDICAL PROVIDER TO COMPLETE THE PCAS PHYSICAL FORM IN ITS ENTIRETY. INSTRUCTIONS HAVE BEEN SENT AS WELL. |
07/01/2025
| Implemented |
| 2380.21(l) | Individual #1 and #2 were not afforded the right to make choices and accept risks.
The Centers for Medicare and Medicaid Services (CMS) requires all states to ensure that individuals are given the opportunity to be actively involved in decision-making about community participation and activities.
There was no documentation to show that Individual #1 participated in a conversation with the Provider to discuss the Individual's preferred community participation and activities between July 1, 2024, and September 30, 2024, and quarterly thereafter.
There was no documentation to show that Individual #2 participated in quarterly conversations with the Provider to discuss the Individual's preferred community participation and activities since their date of admission on 2/18/2025. | An individual has the right to make choices and accept risks. | INDIVIDUAL #1 & #2 COMMUNITY PARTICIPATION AND ACTIVITES MEETINGS WILL BE DOCUMENTED IN OUR MONTHLY MEETINGS. |
07/07/2025
| Implemented |
| 2380.125(f) | Individual #1 takes medication prescribed to treat the symptoms of a diagnosed psychiatric illness and there was not a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | THE PROGRAM SPECIALIST WILL COMPLETE A WRITTEN PROTOCOL FOR ALL INDIVIDUALS WHO TAKE PYSCHIATRIC MEDICATIONS. THE PLAN WILL INCLUDE THE SOCIAL, EMOTIONAL AND ENVIRONMENTAL NEEDS RELATED TO THE SYMPTOMS OF THE PSYCHIATRIC ILLNESS. |
07/07/2025
| Implemented |
| 2380.181(f) | Individual #1's annual assessment, completed and sent to individual plan team members on 9/26/2024, was not provided to the team members at least 30 calendar days prior to the individual plan meeting held on 10/17/2024. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | MANAGING DIRECTOR WILL INFORM THE SC OF THE TIMELY DEADLINES WE ARE REGULATED BY |
07/01/2025
| Implemented |