| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.62 | Sanitary conditions shall be maintained in bathrooms. The men's and ladies' bathrooms wall liquid soap dispenser were leaking, and the agency had what appeared to be square cardboard containers on each bathroom floor catching the liquid soap that was dripping down to the floor. | Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. | Replaced soap and defective soap dispensers. Removed drip tray from the floor in all bathrooms. |
10/31/2025
| Implemented |
| 2390.83(b) | There was no record or documentation from 10/2024-10/2025 on whether or not the alarm was operative each month as the form used indicate or provide this information. | A written record shall be kept showing the date checked, the name of the person checking the alarm and whether or not the alarm was operative. | The monthly fire drill form was updated to indicate if the alarm was operative at the time of the drill, the name of the person checking, as well as the date. |
11/04/2025
| Implemented |
| 2390.151(a) | Individual #1's annual assessment was completed on 8/27/24 and there next one occurred on 10/15/25. | 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. | An Annual Assessment tracking 2390/VTC form was completed which indicates current assessment dates and the date a new assessment needs to be completed. |
11/04/2025
| Implemented |
| 2390.21(l) | Individual #1's ,Individual #2's, and Individual #3's quarterly document for July 1, 2025 thru September 30, 2025 regarding the conversations with Individual #1, Individual #2, and Individual #3 relating to their preferred community participation and activities did not include the documentation of all of the persons involved in the discussion as the document only noted "present Individual #1, Individual #2, and Individual #3" on each of their documents. | A client has the right to make choices and accept risks. | Training was provided to program specialists during the monthly program specialist meeting. The training included the need to document the names of all persons who were involved in the quarterly conversations. |
11/19/2025
| Implemented |
| 2390.151(f) | Individual #1's record includes a letter that their Individual Support Plan (ISP) letter is scheduled for November 19,2025 and there is no record or documentation that their assessment dated 10/15/24 was sent to the team at least 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | A new Annual Assessment tracking form was created that includes the date the assessment was sent to the team, and a check box to indicate it was sent 30 days prior to the Individual Support Plan. |
11/04/2025
| Implemented |