| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | A spray bottle labeled pine sol was found in the cleaning closet during the physical site walk through. | Poisonous materials shall be stored in their original, labeled containers. | The spray bottle was removed immediately from use. Cleaning product was returned to its original manufacturer's container. Any remaining decanted containers were discarded in accordance with safety practices. |
01/16/2026
| Implemented |
| 6400.51(a)(1) | Staff # 11 received only 15 hours of training during the 24-25 training year. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | We missed inclusion of this staff on our self-assessment with others we identified from this training year with insufficient annual hours. This staff, along with all others, have been enrolled in the Relias training program in order to better regulate and record annual training requirements. Our new training year is still mid-cycle. A copy of staff's current training record is attached as # 5 demonstrating enrollment in Relias. |
01/16/2026
| Implemented |
| 6400.52(c)(6) | There is no documentation that Staff # 7, # 13, #15 and # 16 received training in Plan Implementation during 2024 training year. | 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 an individual. | These staff have each received training on the individual plans. Attached are copies of sign-off sheets for staff trainings # 6. These trainings were done timely, but as noted in the citation, the records were not conveyed from the site level records to the training coordinator. Therefore, documentation wasn't present at review. |
01/16/2026
| Implemented |