| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(c) | The poisonous chemicals cabinet in Program Room 5 contained resealable bags of crackers and cookies. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | The resealable bags of crackers and cookies have been removed from the poisonous chemicals cabinet (Attachment #15).
All Program staff and administrators will be retrained on the regulations requiring poisonous materials to be kept separate from food (Attachment # 16). |
09/19/2025
| Implemented |
| 2380.111(a) | Individual 1 had an annual physical dated 10/19/23, and following physical was 02/02/25, which exceeds the annual requirement. Most recent physical on file for Individual 2 is dated 01/25/2024. Individual 3 did not have a physical on file. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | ¿ Individual # 3 physical was completed (Attachment # 13).
¿ Individual # 2 physical was requested (Attachment # 19). |
09/19/2025
| Implemented |
| 2380.111(c)(10) | The 11/07/24 Physical for Individual 4 did not contain 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. | Individual # 4 physical will be updated with medical information pertinent to diagnosis and treatment in case of an emergency (Attachment # 14)
Program Nurses and Program Specialists will be trained on the need to ensure all sections of the individual physical forms are completed in their entirety to include medical information pertinent to diagnosis and treatment of an individual in case of an emergency (Attachment # 2, Attachment # 3). |
09/19/2025
| Implemented |
| 2380.21(l) | The reviewed quarterly discussions with individuals required by ODP Announcement 24-061 were determined to be unreliable - many of the reviewed forms were signed and dated by a program specialist during the inspection rather than the dates the conversation was reported to have occurred. | An individual has the right to make choices and accept risks. | All Program Specialists will be retrained on the documentation regulations regarding quarterly discussions with individuals (Attachment # 4). |
09/19/2025
| Implemented |
| 2380.21(u) | The facility did not provide documentation to support that Individual 4 and legal guardians were informed of individual rights in the current year, and previous year (2024 and 2025). The ISP Know and Do Section, and the provider's Protocol Summary identify the parents as guardians. The copy of their individual rights was acknowledged/signed by the individual and family during the inspection. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | Program Specialists will be retrained on the regulations requiring individual rights to be reviewed with individuals and their guardians annually (Attachment # 5). |
09/19/2025
| Implemented |
| 2380.181(f) | The 10/15/24 annual assessment for Individual 4 was provided to team members on 07/28/25, exceeding the required minimum timeframe.
There was no documentation to support that a copy of Individual 4's 10/01/23 annual assessment was provided to team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | All Program Specialists will be retrained on the documentation regulations regarding assessments being provided to plan team members at least 30 calendar days prior to the individual plan meeting (Attachment # 7). |
09/19/2025
| Implemented |