| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | Program Specialist #1, date of hire 2/20/2017, had physical examinations completed on 2/10/2023 and then again on 2/14/2025. This exceeds the every 2-year requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Program Specialist #1 personnel file was red flagged for non compliance, it will remain so until the physical examination is completed on the scheduled date of 02/01/2027 |
07/28/2026
| Implemented |
| 2380.181(a) | Individual #1's annual assessments were completed on 1/03/2025 and then again on 5/27/2026. This exceeds the annual requirement. | Each individual 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 #2 completed a training with the Program Director on 6/18/2026, which covered 2380.181 Assessment. |
06/18/2026
| Implemented |
| 2380.181(e)(14) | Individual # 1's most recent assessment, completed on 5/11/2026, did not address the individual's knowledge of water safety and ability to swim. This section was left blank. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | Individual #1 assessment was updated to include the completed section on individuals' knowledge of water safety and the ability to swim. The assessment was recorded in his permanent assessment records and distributed to all Team members, via US Mail. Proof of completion will be sent via email |
06/18/2026
| Implemented |