| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | Direct Support Worker #2, date of hire 11/29/24, was not trained in general fire safety during orientation. | 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 home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Direct Support Worker #2 will be trained by the general fire safety trainer for AACS by 6/14/2025. Training will cover all aspects of general fire safety to include evacuation procedures relevant to assigned work sites, responsibility during fire drills, designated meeting locations, smoking safety procedures, use of fire extinguishers and fire alarms, and notifications in emergency situations.
This training was completed for Direct Support Worker #2 at orientation, however proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.46(b) | Program Specialist #1, date of hire 3/29/2022, was not trained in general fire safety during training year, 1/1/2024 through 12/31/2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Specialist #1 will be trained by the general fire safety trainer for AACS by 6/14/2025. Training will cover all aspects of general fire safety to include evacuation procedures relevant to assigned work sites, responsibility during fire drills, designated meeting locations, smoking safety procedures, use of fire extinguishers and fire alarms, and notifications in emergency situations. |
06/27/2025
| Implemented |
| 6400.50(a) | The records of annual training year, 1/1/2024 through 12/31/2024, for Program Specialist #1 did not include the training content. The records of annual training year, 1/1/2024 through 12/31/2024, for Direct Service Worker #2 did not include the training content. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | All staff training files identified as deficient (Program Specialist #1 and Direct Service Worker #2) will be reviewed, and missing content details will be added, to include a training syllabus. This will include specifying the training topic, source, content summary, date(s), length of trainings, and certificates (if applicable). |
06/27/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #3, date of hire 11/29/2024, was not trained on the service plans of the individuals residing in the home. | The orientation must encompass the following areas: Job-related knowledge and skills. | Direct Service Worker #3 will complete Implementation of the Individual Plan by 6/14/2025. The Training Coordinator will complete the training in person and discuss the Support Plan for each individual that resides in the home. Key components will focus on person centered practices, likes and dislikes, effective communication with the individuals we serve, health and safety and desired outcomes.
Annual training for Direct Service Worker #3 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.52(c)(5) | Program Specialist #1, date of hire 3/29/2022, was not trained on the implementation of the individual plans during the annual training year, 1/1/2024 through 12/31/2024. | 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. | Direct Service Worker #1 will be retrained on the safe and appropriate use of behavior supports by 6/14/2025. This will be on-site training that is conducted by the training coordinator. Content will include support plans specific to individuals present in the home. Behavior interventions and specific behavior support plans, when applicable, will be reviewed. Positive reinforcement, crisis intervention, and functional behavior assessments will be reviewed.
Annual training for Direct Service Worker #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |
| 6400.52(c)(6) | Program Specialist #1, date of hire 3/29/2022, was not trained on the implementation of the individual plans during the annual training year, 1/1/2024 through 12/31/2024. | 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. | Direct Service Worker #1 will complete Implementation of the Individual Plan by 6/14/2025. The Training Coordinator will complete the training in person and discuss the Support Plan for each individual that resides in the home. Key components will focus on person centered practices, likes and dislikes, effective communication with the individuals we serve, health and safety and desired outcomes.
Annual training for Direct Service Worker #1 was completed during annual training year 2024 however, proper documentation was not maintained in the employee file. |
06/27/2025
| Implemented |