| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no thermometer in the first aid kit. A thermometer was added to the first aid kit within 24 hours after the inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A thermometer will be kept in the first aid kit at all times. Staff will check the first aid kit monthly to ensue the thermometer is present and functional and will replace it immediately if missing or not working.All checks will be documented, and supervisors will review for compliance. |
12/30/2025
| Implemented |
| 6400.52(c)(1) | There was no record on file to show that Staff 1 was trained in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | All staff will complete their required annual training hours. The program specialist will oversee and ensure compliance with training requirement including tracking completion and maintaining documentation |
01/05/2026
| Implemented |
| 6400.52(c)(3) | There was no record on file to show that Staff 1 was trained in Individual Right's. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | All staff will complete their required annual trining yearly. The Program Specialist will oversee and ensure compliance with training requirement including tracking completion and maintaining documentation |
01/05/2026
| Implemented |
| 6400.52(c)(4) | There was no record on file to show that Staff 1 was trained in Recognizing and Reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | All staff will complete their required annual trining yearly. The Program Specialist will oversee and ensure compliance with training requirement including tracking completion and maintaining documentation |
01/05/2026
| Implemented |
| 6400.52(c)(6) | There was no record on file to show that Staff 1 was trained in the Implementation of the individual plan of the person they work directly with. | 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. | All staff will complete their required annual trining yearly. The Program Specialist will oversee and ensure compliance with training requirement including tracking completion and maintaining documentation |
01/05/2026
| Implemented |