| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | On 1/8/2026 at 1:00pm, a 473mL bottle of GelRite Instant Hand Sanitizer with Vitamin E, with instructions to contact a physician or Poison Control Center in case of accidental ingestion, was observed on the bottom shelf of the unlocked left-side craft cabinet in program room L3. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Immediately upon identification, the hand sanitizer was removed from the unlocked craft cabinet and secured in a locked storage area inaccessible to individuals. Program room L3 was checked to ensure no other potentially poisonous materials were accessible to individuals.
The Program Instructors are responsible for ensuring that hazardous and poisonous materials are stored appropriately. Program Instructors are responsible for maintaining safe storage during daily program operations.
All program rooms were reviewed to identify and secure any additional poisonous or hazardous materials. |
01/12/2026
| Implemented |
| 2380.111(c)(5) | Individual #1, date of admission 5/1/2025, had their most recent tuberculin skin test via Mantoux method completed on 11/5/2022. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Director Kelly Suppa will implement an immunization tracking system for the Program Specialists to monitor due dates for all required immunizations. The Program Specialists' audit form will be reviewed at least monthly by the Program Specialists to ensure immunizations remain current. Program Specialists will review and sign off on their audit sheets that they have ensured compliance with all regulatory dates (see attachment B). |
01/12/2026
| Implemented |
| 2380.111(c)(10) | Individual #2's physical examination, completed 5/15/2025, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical examination form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The individual's primary care provider was contacted on January 12, 2026, by Program Specialist Tory Graham, who requested completion of the section addressing medical information pertinent to diagnosis and treatment in case of an emergency. The Doctor's office stated that they will update the Medical information pertinent to diagnosis and treatment in case of an emergency on the individual's next physical in May of 2026.
The Program Specialist is responsible for obtaining completed physical examinations and following up with guardians and/or medical providers. |
01/12/2026
| Implemented |