| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(1)(iii) | On 8/28/2025 Individual #1's record did not include the language or means of communication spoken or understood by the individual. It was blank. | Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English. | Language and means of communication have been added to the emergency form. |
09/10/2025
| Implemented |
| 2380.181(e)(12) | Individual #1's assessment completed 5/01/2025 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Individual #2's assessment completed 4/03/2025 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. | Recommendations for specific areas of training, vocational programming and competitive community-integrated employment have been added to the assessment for both individuals. |
09/12/2025
| Implemented |
| 2380.17(h)(4) | Individual #3 had an Enterprise Incident Management neglect incident # 9561700 discovered 1/31/2025, which was assigned to a certified investigator 1/31/2025, and the first interview was conducted 2/03/2025. | A Department-certified incident investigator shall conduct the investigation of: Neglect. | All agency CI's have been retrained on the CI manual guidance. |
09/15/2025
| Implemented |
| 2380.36(b) | Direct Service Worker #2's most recent fire safety training occurred 8/16/2024. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The staff person was retrained on fire safety on 8/28/25. |
09/15/2025
| Implemented |
| 2380.37(a) | Direct Service Worker #1 has documentation of completing 18 hours of annual training 1/19/2024, which is not the actual length of time for the training. Direct Service Worker #2 has documentation of completing 24.5 hours of training 7/22/2024. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | All agency guidelines were sent out regarding training requirements and POC. All Program Specialists and directors reviewed. |
09/11/2025
| Implemented |
| 2380.182(c) | Individual #1's assessment completed 5/01/2025 states he is able to sense and move away from heat sources independently. Individual #1's individual support plan, last updated 8/21/2025, states he requires verbal reminders about heat sources. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individuals' needs were reevaluated, and the program assessment has been updated to reflect the changes. |
09/12/2025
| Implemented |