| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(c) | The fire drill conducted on 7/30/24 did not include the time the fire drill was conducted as this section was left blank on the form. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | Staff have been retrained on filling out all spaces of the fire drill correctly and completely. This was completed by the Director to the Manager of the ATF program |
01/21/2025
| Implemented |
| 2380.89(d) | The fire drill conducted on 3/4/24 at 9:30 am had an evacuation time of 3:29 (three minutes and 29 seconds), the fire drill conducted on 5/16/24 at 11:30 am had an evacuation time of 2:45 (two minutes and 45 seconds), which exceeds the 2 ½ minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | All staff have been retrained in the regulation concerning fire drills over 2 minutes 30 seconds. Moving forward staff will also notify the Director of any drills that are over the time limit. |
01/21/2025
| Implemented |
| 2380.111(c)(7) | Individual #2's physical examination dated 10/21/24 did not include health maintenance needs as this section of her physical examination was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Director has retrained Managers and Program Specialist about looking over a physical when it is returned to ensure that all parts of the physical are completed. |
01/21/2025
| Implemented |
| 2380.21(l) | There was no record of documentation in Individual #1 and Individual #2's files that the agency had at least one conversation and documented it from July 1, 2024, through September 30, 2024, regarding conversations with Individual #1 and Individual #2 relating to their preferred community participation and activities at least quarterly. | An individual has the right to make choices and accept risks. | Program Specialist was retrained that this regulation also covers 2380 programs as well as the 2390's. |
01/21/2025
| Implemented |
| 2380.21(u) | Individual #2 did not have a review of their rights in 2024. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | The Individual was attending the ATF the day of inspection and this was reviewed and completed with them. The Program Specialist was retrained on watching the due dates for each Individuals especially when they started outside of the new year. |
12/27/2024
| Implemented |