| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.85(c) | The fire drill record form for the fire drill conducted on 9/23/25 at 12:10 PM did not include documentation that all clients evacuated the entire building during the fire drill as the "total evacuation" section of the form was left blank. | Clients shall evacuate the entire building during each fire drill. | All staff were retrained on ensuring that the fire drill records are completed in full. This includes marking that there was a total evacuation for the drill. |
03/13/2026
| Implemented |
| 2390.111(a) | There was no record or documentation that Individual #1 had a preadmission interview. | A client shall have a preadmission interview. | a new form was created to that will be attached to the letter that is sent to the Individual after the preadmission interview |
03/16/2026
| Implemented |
| 2390.151(a) | Individual #1's date of admission is 10/30/25 and their initial assessment was completed on 01/02/2026. Individual #1's assessment was completed 64 days after their admission into the facility. | 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. | Program Specialists were retrained on the regulation ensuring that the initial assessment is sent 60 days or before of the admission into the facility. |
03/13/2026
| Implemented |
| 2390.49(c)(6) | Staff #1 did not receive training in the implementation of the individual support plans during the training year July 1, 2024, through June 30, 2025. | 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 a client. | Program Specialists were retrained to ensure they are marking on their annual training log how many hours they spent with implementation of the Individuals ISP's over the course of a training year. |
03/13/2026
| Implemented |
| 2390.151(f) | Individual #2's Individual Support Plan (ISP) meeting was 9/23/25, their annual assessment was completed 8/22/25, and the assessment was sent to the team members, Supports Coordinator, on 9/4/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | Program Specialists were retrained on the regulation and given an example of how inspectors are looking at the 30- day date. It was explained that it is when they have notified Team members of the assessment not when they actually completed it. |
03/13/2026
| Implemented |