| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.84 | The agency's annual onsite fire safety inspections were completed by a fire safety expert on 8/8/2024 and then again on 8/12/2025. | 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 inspection will be scheduled by the Assistant Director no later than July 2026, ensuring completion before August 8, 2026.
-A fire drill schedule will be utilized that will include the annual fire drill date. The 2026 annual fire drill is scheduled for July 27, 2026
- The Director will implement a Google Calendar system reminder (e.g., calendar alerts) that will be implemented at least 60 days before the due date each year.
- The Assistant Director will verify completion of the fire safety inspection and proper documentation during the facility's monthly safety meeting. |
11/21/2025
| Implemented |
| 2380.38(b)(5) | Direct Service Worker #4, date of hire 7/7/2025, did not participate in training to include job-related knowledge and skills during orientation. According to the agency's orientation syllabus, Direct Service Worker #4 independently read the content of the training on 7/11/2025. | The orientation must encompass the following areas: Job-related knowledge and skills. | Update the orientation syllabus to include the trainer, the length of training, and a description of the training. |
11/21/2025
| Implemented |
| 2380.39(c)(6) | Program Specialist #1, Program Instructor #2, and Direct Service Worker #3 did not participate in training to include the implementation of the individual plan for the individuals whom they work directly with during the 1/1/2024 through 12/31/2024 annual training year. | 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. | -Program Specialist #1, Program Instructor #2, and Direct Service Worker #3 will complete training on the implementation of the individual plans for all individuals they support by 11/21/25.
-Supervisors will verify completion of all required training through signed ISP in-service form training sheets.
-Staff are to sign the in-service form after being trained on the ISP, stating that they have an understanding of the ISP document and the individual that they will be working directly with. |
11/21/2025
| Implemented |