| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.91(a) | Individual #1's 11/04/24 and Individual #3's 03/03/25 fire safety training did not include the location of the designated meeting place outside of the building. | 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. | On 05/12/2025 individuals 1 and 3 completed a fire drill and fire safety training, where the location of the designated meeting place was discussed and used. |
05/12/2025
| Implemented |
| 2380.111(a) | Individual #3'sphysical completed on 4/3/25, does not document their immunizations, does not indicate if they are free from communicable diseases, or list the information pertinent to treat/diagnose in the event of an emergency. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | CARES faxed the blank physical form to be filled out on 4/17/25, and again on 5/6/25. To date, 5/9/25, CARES has not received the completed physical form back yet (Attachment #3). The Program Specialist will follow up weekly. |
05/09/2025
| Implemented |
| 2380.111(c)(9) | It is unclear is what Individual #2's allergies are. The physical completed on 1/20/25 documents that they are allergic to Sulfa Drugs and Tobamyacin. The face sheet, ISP, and assessment for Individual #2 only documents the Sulfa allergy. According to Individual #1's ISP and face sheet they are allergic to Penicillin and Lactose. The assessment only lists the allergy to the Penicillin. The physical completed on 9/19/24 does not document any allergies for Individual #1. Individual #3's physical completed on 4/3/25, does not document what their allergies are. The section is blank. | The physical examination shall include: Allergies or contraindicated medication. | Individual #1's allergy discrepancy has been resolved as lactose is an old allergy that no longer exists (Attachment #4). Individual #2's allergies have been corrected on the fact sheet and the assessment, as well as track changes being completed and emailed to the team (Attachment #5). Individual #3's allergies on the physical were completed by the doctor and returned to CARES (Attachment #6). |
05/09/2025
| Implemented |
| 2380.173(1)(v) | Individual #2's photo was taken 4/2/24 and not again since, outside of the annual timeframe. | Each individual's record must include the following information: Personal information including: A current, dated photograph. | On 05/08/2025, individual #3's updated photo from 03/18/25 was added to the fact sheet (Attachment #7). |
05/09/2025
| Implemented |
| 2380.183(a)(3) | Individual #1's 2/12/25 ISP team meeting did not include a direct care staff. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | On 05/06/2025, a DSP reviewed and signed the ISP meeting note (Attachment #8). |
05/09/2025
| Implemented |