| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(a) | Individual #1 had an assessment completed 8/05/2022 and then again 8/29/2023. | Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Program Specialist will use a spread sheet and white board to track dates of assessments. Also, adding signatures and initials checklist to be sure items are completed in the required time period. |
04/30/2024
| Implemented |
| 2390.151(d) | Individual #1's assessment completed 8/29/2023 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | Program Specialist will double check paperwork. This will include signatures completed and dates of completion for all annual assessments. |
04/30/2024
| Implemented |
| 2390.21(u) | Individual #1 was informed of client rights 12/21/2022 and then again 1/05/2024. Individual #2 was informed of client rights 12/19/2022 and then again 1/05/2024. Individual #3 was informed of client rights 12/22/2022 and then again 1/11/2024. Individual #4 was informed of client rights 12/19/2022 and then again 1/08/2024. | 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. | VP of Mission Services created a spreadsheet with all participants. This includes the date of the last signed policy 66 review of individual rights. Also, the date of the next review and signature is noted. VP of Mission will annually alert Program Specialist of the necessary dates to be reviewed and signed with each participant. |
04/30/2024
| Implemented |
| 2390.49(c)(6) | Floor supervisor #1 and Floor supervisor #2 have no documentation of completing training in implementation of the individual plans for the annual training year from 1/01/2023 through 12/31/2023. | 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 a client. | VP of Mission will annually print the ISP's for staff. Staff will read/ review the ISP and sign and date. VP will be responsible to be sure this happens within the 365 day timeframe. |
04/30/2024
| Implemented |
| 2390.151(f) | Individual #2's assessment completed 1/29/2024, was sent to the individual plan team members 1/29/2024, for the individual meeting which occurred 2/13/2024. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | Program Specialist will use a spread sheet and white board to track pertinent dates, annual meetings, and dates to send assessments in the required timeframe. |
04/30/2024
| Implemented |