| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.61 | The toilets in the men's bathroom are not fully secured to the floor and easily shift and move when pushed. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | General manager was present for onsite inspection. GM requested maintenance tighten item and picture is attached for reference. |
09/25/2025
| Implemented |
| 2390.151(a) | Individual #2 was admitted to the facility on 5/12/25 and the initial assessment was not completed until 8/11/25, which is not within the 60-day requirement. | 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. | Director of Hablitation reviewed this item with Program Specialist which completed initial assessment. 2390 Regulation was reviewed with this particular program specialist. |
10/06/2025
| Implemented |
| 2390.21(l) | The provider did not hold quarterly conversations with Individual #3 relating to their preferred community participation and activities as required by ODP Announcement 24-061. Documented conversations were found in the file dated 1/27/25 and 4/22/25 only. | A client has the right to make choices and accept risks. | Individual transferred from another location which closed and Program Specialist responsible for documentation oversight is no longer employed with APS. |
10/06/2025
| Implemented |
| 2390.153(b) | For Individual #1, two (2) team members, including the individual, attended the 03/27/2024, and 03/26/2025 ISP Meetings, and a minimum of three (3) team members in addition to the individual are required to be present. | At least three members of the individual plan team, in addition to the client and persons designated by the client, shall be present at a meeting at which the individual plan is developed revised. | Director of Hablitation reviewed this item with Program Specialist which completed initial assessment. 2390 Regulation was reviewed with this particular program specialist. |
10/06/2025
| Implemented |