| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(9) | Individual #1's annual assessment, completed 1/13/2025, did not include functional and medical limitations. This section of the assessment stated, "Functional and medical limitations can be found in consumer's most recent physical." Individual #1's physical examination was not attached to the assessment or provided to the plan team as part of the assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Program Specialist amended Individual #1's assessment on 8/28/25 to include documentation of
functional and medical limitations, as required.
Additionally, the Compliance Officer conducted a company-wide review of all assessments to identify
and remediate any similar omissions. All affected assessments were corrected by 9/1/25. |
09/01/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment, completed 1/13/2025, did not include recommendations for specific areas of training, programming and services. The assessment stated under Specific areas of training "Staff are trained in [Individual #1's] BSP, First Aid and CPR, Medication Administration" and under Recommended Programs/Services "Continued Residential Services; Continued Behavior Support Services." The assessment's recommendations were not specific to Individual #1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist amended the assessment on 8/28/25 to include individualized recommendations for [Individual #1], such as fire safety training and demonstration during monthly fire drills.
The Compliance Officer also completed a company-wide review of all assessments to identify and remediate any similar omissions, with corrections completed by 9/1/25. |
09/01/2025
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 1/13/2025, stated "[Individual #1] typically will evacuate for a fire drill, but if the weather is bad, or if she is in the middle of a preferred activity, she may delay. Staff set the alarms off and use verbal prompts to get her to evacuate in the allowed time. Individual #1's support plan, last updated 8/12/2025, states "[Individual #1] responds appropriately to fire drills. She participates in monthly fire drills and annual fire safety training at her home. During fire drills, staff provide line of sight supervision to ensure that [Individual #1] is able to safely and independently exit the home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Program Specialist updated the assessment and ISP on 8/28/25 to ensure consistency in describing Individual #1's response to fire drills.
A company-wide review of assessments and ISPs was conducted by the Compliance Officer to identify and remediate any similar inconsistencies, with all corrections completed by 9/1/25. |
09/01/2025
| Implemented |