| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(12) | Individual #1's assessment, completed 2/17/2025, does not include recommendations for specific areas of vocational training or placement and competitive community-integrated employment. Individual #3's assessment completed on 4/14/2025 recommendations for specific areas of vocational training or placement and competitive community-integrated employment was marked as not applicable. Individual #4's assessment completed on 12/12/2024 recommendations for specific areas of vocational training or placement and competitive community-integrated employment was marked as not applicable. Individual #5's assessment completed on 3/22/2025 recommendations for specific areas of vocational training or placement and competitive community-integrated employment was marked as not applicable. | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | The annual assessment form has been updated to include an area for a narrative of recommendations for specific areas of vocational training or placement and competitive community-integrated employment.
Individual #1's assessment was revised 7/21/25 and resubmitted to SC to have the following information added to her ISP. V has attended her Community Participation Supports program sporadically since staying home during Covid. It is our vocational recommendation that she come to work on her scheduled days to establish a work routine similar to that which would be required in a competitive employment environment. V works at a very deliberate pace which also needs to increase in order for her to obtain competitive employment.
Individual #3's assessment was revised 7/21/25 and resubmitted to SC to have the following information added to his ISP. B is working toward competitive integrated employment. He finished school in February and has been experiencing a variety of jobs to determine what type of work is of interest to him. It is recommended that as he finds his preferences, he also develop his ability to focus on the task at hand in order to improve the quality of his work and increase the time it takes to accurately complete his tasks. B also needs to improve his social interactions with co-workers and supervisors. He is currently being presented with a variety work and volunteer opportunities so that he can develop the skills mentioned so that he can move to competitive integrated employment.
Individual #4's assessment was revised 7/21/25 and resubmitted to SC to have the following information added to her ISP. D participates in Small Group Employment in order to build skills to move to competitive integrated employment. She currently uses her janitorial skills to clean a local business office. She has good skills, but she moves at a very deliberate pace and will not change jobs until she has completed one task even if employer needs something else done. It is our vocational recommendation that Diana continue with Small Group Employment to enhance her pace and develop greater flexibility skills so she can meet an employer¿s expectations.
Individual #5's assessment was revised 7/21/25 and resubmitted to SC to have the following information added to her ISP. J is receiving Community Participation Supports in order to prepare for competitive integrated employment. J considered Small Group Employment in the past, but ultimately declined to participate in it. It is our vocational recommendation that J develop her stamina and speed so she can move to competitive integrated employment. |
07/21/2025
| Implemented |
| 2390.151(e)(13)(i) | Individual #2's assessment, completed 10/6/2024, does not address health. This section was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | Program Specialist reviewed Individual #2's file, completed the Health progress which was good and notified SC that she had failed to complete the Health section and conveyed this updated information through a revised ISP. This correction and notification occurred on 07/02/2025. |
07/18/2025
| Implemented |
| 2390.21(u) | Individual #2 was informed and explained individual rights on 11/9/2023 and then again on 11/12/2024. | 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. | A master spreadsheet has been created listing when individuals were last informed of rights. These forms will continue to be sent home, but if they are not returned prior to last date signed, staff will review rights with participants within the annual time frame and have them sign the document. |
07/21/2025
| Implemented |
| 2390.152(c) | Individual #3's assessment completed on 4/14/2025 indicated he is able to independently evacuate in 2 ½ minutes or less. The fire safety section of Individual #3's individual plan that was last updated on 6/23/2025 reads, "[Individual #3] requires verbal prompting to go in the direction of designated exit." | The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment. | Individual #3's assessment was revised on 7/21/2025 and the assessment was resubmitted to the SC. The change is as follows: Individual #3 leaves the Center independently when the alarm sounds. He moves with the group and evacuates because he knows the routine in this place. He would need verbal support in unfamiliar environments. |
07/21/2025
| Implemented |