| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.84 | An onsite fire safety inspection by a fire safety expert has not been conducted. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | Actions to be taken immediately: What should we do right now?
1. NFHCS created a Fire Safety Inspection Record Template (11.11.25) (attached)
2. Fire safety expert completed inspection on 11.18.25. (Please see attached fire safety documentation and expert's credentials.)
3. Restructured REACH Day Program management, Chief Executive Assistant (CEA) will oversee fire safety inspections and maintain records. |
11/28/2025
| Implemented |
| 2380.89(g) | The fire drill conducted on 2/14/2025 did not address if the individuals evacuated to a designated meeting place outside the building or within the fire safe area. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Actions to be taken immediately: What should we do right now?
1. REACH program administration structure has changed, allowing the Program Specialist to concentrate on 2380.89 regulatory activities. Program Specialist (PS) will conduct monthly fire drills in accordance with 2380.89. (Please see attached documentation)
2. REACH program will be supervised by the Chief Executive Assistant (CEA) who will review all fire drills, once completed, to assure compliance with 2380.89 regulations.
3. Not Forgotten updated it's Site Specific fire drill training for staff and all staff were retrained in responsibilities during fire drills on 11/18/25 (see attached) |
11/28/2025
| Implemented |
| 2380.91(a) | Individual #1, date of admission 7/21/2025, was initially instructed in the individual's primary language or mode of communication in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility on 10/23/2025.
Individual #2, date of admission 6/04/2025, was initially instructed in the individual's primary language or mode of communication in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility on 6/30/2025.
Individual #3, date of admission 2/11/2025, was initially instructed in the individual's primary language or mode of communication in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility on 5/27/2025.
Individual #4, date of admission 2/19/2025, was initially instructed in the individual's primary language or mode of communication in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility on 5/27/2025. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Actions to be taken immediately: What should we do right now?
1. Individual(s )were retrained on 11.18.25 (please see attached sheet)
2. Created an onboarding checklist on 11.21.25 that includes all individual trainings required prior to admission.
3. REACH Program Specialist has reviewed 2380.91 regarding fire safety training for individuals. (see attached)
4. Chief Executive Assistant (CEA) will verify completion of individual fire safety training.
5. Individual(s) will not be able to move forward with admission unless 2380.91 requirement is met.
6. All new admissions moving forward will complete fire safety training prior to admission or immediately upon first date of program attendance in order to maintain compliance with 2380.91.
7. NFHCS REACH has restructured leadership within the REACH program, allowing the current Program Specialist to manage and focus on maintaining compliance with 2380 regulations. |
11/28/2025
| Implemented |
| 2380.111(c)(3) | Individual #2's most recent tetanus, diphtheria, and pertussis vaccination was administered on 10/04/1973. This exceeds the every 10-year recommendation by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Actions to be taken immediately: What should we do right now?
1. Individual #2 (TT) received TDAP immunization at pharmacy on 11.18.25. (see attached).
2. REACH program administration structure has changed, allowing the Program Specialist to concentrate on 2380.111c3 regulatory activities. (Please see attached documentation)
3. REACH program will be supervised by the Chief Executive Assistant (CEA) who will review all immunization records, once completed, to assure compliance with 2380.111c3 regulations. |
11/28/2025
| Implemented |
| 2380.111(c)(10) | Individual #4's physical examination completed on 7/02/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Actions to be taken immediately: What should we do right now?
1) On 11.24.25. Individual #4's physical examination was returned by fax to their PCP for completion. Individual #4's PCP did not complete documentation as requested and it was returned to them on 11/26/25 to rectify. (see attached documentation) |
11/28/2025
| Implemented |
| 2380.113(a) | Direct Service Worker #2, date of hire 4/07/2025, had their initial physical examination completed on 4/17/2025. This is not within 12 months prior to employment. Direct Service Worker #4, date of hire 2/18/2025, had physical examinations completed on 5/08/2023 and then again on 5/04/2025. Neither physical examination is within 12-months prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | RE: Staff #2
Actions to be taken immediately: What should we do right now?
1) Staff #2 (TA) will be sent for a new TB/Physical that has been submitted and reviewed for compliance prior to returning to work (see attachment)
2) Not Forgotten also created a TB/Physical Process, ensuring that all documentation including physical forms and trainings are compliant moving forward. HR team will be trained on this process.
3) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR.
4) NFHCS has restructured the HR Team, adding additional staff to assist with the staffing record management process.
5) Not Forgotten HR team reviewed the record management Process, new hire checklist, & employment change process ensuring all documentation including physical forms and trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.113.
RE: Staff #4
Actions to be taken immediately: What should we do right now?
1) Currently #4 (BU) is on medical leave. Upon return, BU will be sent for a new TB/Physical that must be submitted and reviewed for compliance prior to returning to work
2) Not Forgotten created a TB/Physical Process (See attached), ensuring that staff moving to positions between programs are treated as newly onboarded so that all documentation including physical forms and trainings are compliant moving forward. HR team has been trained on this process.
3) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR. (credentials attached)
4) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
5) Not Forgotten HR team reviewed the record management Process, new hire checklist, & employment change process ensuring that HR staff moving to positions between programs are treated as newly onboarded so that all documentation including physical forms and trainings are compliant moving forward. Records are properly maintained and monitored according to 2380.113a. HR team will be trained on this process. |
11/28/2025
| Implemented |
| 2380.181(e)(1) | Individual #1's assessment completed on 9/22/2025 did not include functional strengths, needs, and preferences of the individual.
Individual #2's assessment completed on 8/04/2025 did not include functional strengths, needs, and preferences of the individual.
Individual #3's assessment completed on 4/11/2025 did not include functional strengths, needs, and preferences of the individual.
Individual #4's assessment completed on 4/19/2025 did not include functional strengths, needs, and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process, the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (attached) |
11/28/2025
| Implemented |
| 2380.181(e)(2) | Individual #2's assessment completed on 8/04/2025 did not include the dislikes of the individual. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process - the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) for individuals 1-4 were completed by 11/26/25 and submitted to the SC/team. (attached) |
11/28/2025
| Implemented |
| 2380.181(e)(4) | Individual #1's assessment completed on 9/22/2025 did not include the individual's need for supervision. | The assessment must include the following information: The individual¿s need for supervision. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (attached) |
11/28/2025
| Implemented |
| 2380.181(e)(5) | Individual #1's assessment completed on 9/22/2025 did not include the individual's ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (See attached)
Policy/ Procedures/ Process/ Training changes or Implementation:
1. REACH Program Specialist will be trained on 2380.181e5 regarding assessments (See attached)
2. Assessments will be completed in the administration approved format similar to our residential program in which all applicable 2380.181 categories will be documented with explanation.
3. Assessments will only be completed using the pre-approved format and will be reviewed by CEA in order to ensure that they are compliant with 2380.181e5. |
11/28/2025
| Implemented |
| 2380.181(e)(6) | Individual #1's assessment completed on 9/22/2025 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.
Individual #2's assessment completed on 8/04/2025 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.
Individual #3's assessment completed on 4/11/2025 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.
Individual #4's assessment completed on 4/19/2025 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (See attached) |
11/28/2025
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment completed on 9/22/2025 did not include a lifetime medical history.
Individual #2's assessment completed on 8/04/2025 did not include a lifetime medical history.
Individual #3's assessment completed on 4/11/2025 did not include a lifetime medical history.
Individual #4's assessment completed on 4/19/2025 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (See attached) |
11/28/2025
| Implemented |
| 2380.181(e)(12) | Individual #1's assessment completed on 9/22/2025 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.
Individual #2's assessment completed on 8/04/2025 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.
Individual #3's assessment completed on 4/11/2025 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.
Individual #4's assessment completed on 4/19/2025 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant(CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (See attached) |
11/28/2025
| Implemented |
| 2380.181(e)(14) | Individual #1's assessment completed on 9/22/2025 did not include the individual's knowledge of water safety and ability to swim.
Individual #2's assessment completed on 8/04/2025 did not include the individual's knowledge of water safety and ability to swim.
Individual #3's assessment completed on 4/11/2025 did not include the individual's knowledge of water safety and ability to swim.
Individual #4's assessment completed on 4/19/2025 did not include the individual's knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | Actions to be taken immediately: What should we do right now?
1. Based off of our internal investigation where staff was using a non-authorized assessment format (see attached), NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process -the Chief Executive Assistant (CEA) and identified a new Program Specialist.
2. The correct assessment(s) were completed by 11/26/25 and submitted to the SC/team. (See attached) |
11/28/2025
| Implemented |
| 2380.36(a) | Direct Service Worker #1's initial fire safety training completed on 1/09/2025 did not include evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department as soon as possible after a fire is discovered.
Direct Service Worker #2's initial fire safety training completed on 4/11/2025 did not include evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department as soon as possible after a fire is discovered.
Program Specialist #3's fire safety trainings completed on 10/02/2024, 2/04/2025, and 10/31/2025 did not include evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department as soon as possible after a fire is discovered.
Direct Service Worker #4's initial fire safety training completed on 2/04/2025 did not include evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department as soon as possible after a fire is discovered. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Actions to be taken immediately: What should we do right now?
1. Create a Fire Safety Training Record template (attached)
2. Staff #1-4 have completed this portion of training by 11.18.25.
3. HR Department will house records that the training was completed
4. NFHCS has restructured the HR team, removing the HR Specialist, and adding additional team members to assist with staffing records. (see attached)
5. NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. Staff are not permitted to change any documentation/forms without authorization. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist.
6. NFHCS has created a new hire orientation/training checklist (attached) in order to ensure that 2380.36a is completed prior to staff working with individuals. |
11/28/2025
| Implemented |
| 2380.38(b)(1) | Direct Service Worker #2, date of hire 4/07/2025, began working with individuals on 4/09/2025, but was not trained on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships until 4/11/2025. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Actions to be taken immediately: What should we do right now?
1) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
2) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR. (see attached credentials) The new HR Manager will oversee the HR team.
3) Not Forgotten HR manager & team has been trained on the record management process, new hire checklist, & employment change process ensuring all documentation including 2380.38 trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.38b1. |
11/28/2025
| Implemented |
| 2380.38(b)(2) | Direct Service Worker #2, date of hire 4/07/2025, began working with individuals on 4/09/2025, but was not trained on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations until 4/11/2025. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Actions to be taken immediately: What should we do right now?
1) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
2) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR. (see attached credentials) The new HR Manager will oversee the HR team.
3) Not Forgotten HR manager & team has been trained on the record management process, new hire checklist, & employment change process ensuring all documentation including 2380.38b2 trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.38b2. |
11/28/2025
| Implemented |
| 2380.38(b)(3) | Direct Service Worker #2, date of hire 4/07/2025, began working with individuals on 4/09/2025, but was not trained on individual rights until 4/11/2025. | The orientation must encompass the following areas: Individual rights. | Actions to be taken immediately: What should we do right now?
1) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
2) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR. (see attached credentials) The new HR Manager will oversee the HR team.
3) Not Forgotten HR manager & team has been trained on the record management process, new hire checklist, & employment change process ensuring all documentation including 2380.38b3 trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.38b3.
Policy/ Procedures/ Process/ Training changes or Implementation:
1) Not Forgotten HR manager & team has been trained on the record management process, new hire checklist, & employment change process ensuring all documentation including 2380.38b3 trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.38b3. |
11/28/2025
| Implemented |
| 2380.38(b)(4) | Direct Service Worker #2, date of hire 4/07/2025, began working with individuals on 4/09/2025, but was not trained on recognizing and reporting incidents until 4/14/2025. | The orientation must encompass the following areas: Recognizing and reporting incident. | Actions to be taken immediately: What should we do right now?
1) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
2) NFHCS has recently hired a new HR Manager who has over 20 years experience in HR and a degree in HR. (see attached credentials) The new HR Manager will oversee the HR team.
3) Not Forgotten HR manager & team has been trained on the record management process, new hire checklist, & employment change process ensuring all documentation including 2380.38b4 trainings are compliant moving forward so that records are properly maintained and monitored according to 2380.38b4. |
11/28/2025
| Implemented |
| 2380.38(b)(5) | Direct Service Worker #2, date of hire 4/07/2025, did not have documentation of being trained on the Individual Support Plans for any individuals. | The orientation must encompass the following areas: Job-related knowledge and skills. | Actions to be taken immediately: What should we do right now?
1) NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. NFHCS placed a new staff to oversee the assessment process - the Chief Executive Assistant (CEA) and identified a new Program Specialist. (credentials attached)
2) NFHCS has restructured the HR team, adding additional team members to assist with staffing records.
3) Staff #2 will complete review of individual's ISP's and acknowledgement signature page upon his return to work at the REACH program on 12/2/25 as this is his next scheduled date to work at program.
4) TA will not work with individuals until this portion of training is completed in order to comply with 2380.38b5. |
12/05/2025
| Implemented |
| 2380.129(a) | Program Specialist #4, who is not qualified to administer prescription medications, administered the following prescription medication to Individual #5 on 10/06/2025 at 8:00 PM: Ammonium Lactate 12% with directions to apply topically to feet twice daily at 8:00 AM and 8:00 PM. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Actions to be taken immediately: What should we do right now?
1) PS #4's initial training occurred prior to the change in the Med Administration Course. Initial documents have been located after the occurrence of the 2380 site licensing audit. However, NFHCS did not locate their initial med training course. NFHCS initiated changes with the HR Management team to ensure proper record keeping.
a. An HR Manager was recently hired to oversee the HR Department
b. HR Specialists were added in order to ensure proper record keeping
2) PS #4 documentation of course completion as well as observations and MAR reviews will be housed according to record management process within the HR department.
3) PS #4 did additional training and was able to obtain certificate and provided this to HR on 11/21/25 (please see attached) despite having already been trained.
4) REACH Program has identified additional back up staff who have medication training certificates on file who are able to pass medications during program hours. (please see attached training certificate(s)). |
11/28/2025
| Implemented |
| 2380.181(f) | Individual #1's assessment completed on 9/22/2025 was documented as sent to the individual plan team members, but the original correspondence letter had the date sent redacted, therefore compliance is unable to be measured.
Individual #2's assessment completed on 8/04/2025 was documented as sent to the individual plan team members, but the original correspondence letter had the date sent redacted, therefore compliance is unable to be measured.
Individual #3's assessment completed on 4/11/2024 was documented as sent to the individual plan team members, but the original correspondence letter had the date sent redacted, therefore compliance is unable to be measured. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Actions to be taken immediately: What should we do right now?
1. NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist. (credentials attached) NFHCS will also use an Administrative Assistant for Recordkeeping purposes for the REACH program.
2. Assessments have been re-completed by 11/26/25 in order to address additional 2380.181 violations.
3. IMMEDIATELY upon completion assessments will be sent to respective team/SC. (see attached)
4. E-mail documentation will be kept. |
11/28/2025
| Implemented |
| 2380.182(c) | Individual #1's assessment completed on 8/04/2025 states the individual is completely independent in community participation, but the Individual Support Plan last updated 7/01/2025 states the individual is always supervised in the community.
Individual #3's assessment completed on 4/11/2025 states the individual has 1:6 supervision in the facility and 1:3 supervision in the community, but the Individual Support Plan last updated 6/24/2025 states the individual "attends the Step by Step CPS Program at a 1:3 staffing ratio."
Individual #4's assessment completed on 4/19/2025 states the individual is able to independently evacuate in the event of a fire, but the Individual Support Plan last updated 9/23/2025 states the individual can evacuate with verbal prompting and would not be able to independently recognize an emergency.
Individual #4's assessment completed on 4/19/2025 states the individual has 1:6 supervision in the facility and 1:3 supervision in the community, but the Individual Support Plan last updated 9/23/2025 states the individual "attends the Step by Step ATF three days a week for up to 18 hours a week." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Actions to be taken immediately: What should we do right now?
1. NFHCS restructured the REACH day program immediately to ensure that compliance will be maintained. NFHCS placed a new staff to oversee the assessment process the Chief Executive Assistant (CEA) and identified a new Program Specialist. (credentials attached)
2. Assessments were not being checked against the ISP for revisions by the previous Program Specialist, this person was removed as the Program Specialist and the REACH program has been restructured. The CEA will now oversee the REACH program and assessments with the new Program Specialist working under the CEA's supervision.
3. Assessments will be cross checked against the individual's ISP for accuracy. Program Specialist supervisor (CEA) will review and approve of changes that are to be requested by signing off. This will occur by 12.5.25 in order to bring this portion of the assessment process back into compliance.
4. Any outdated or inaccurate information found within the ISP will be identified and Service Coordinator will be contacted via email requesting changes that need to be made.
5. Copies of e-mail requests sent to Service Coordinator will be kept along with ISP for recordkeeping purposes to verify that request for update was made. |
12/05/2025
| Implemented |