| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(a) | Individual #1's assessment was completed on 2/9/24 and their next annual assessment was completed on 3/4/25. Individual #2 had an assessment completed on 11/2/23 and their next assessment wasn't completed until 2/13/25. This exceeds the requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Provider will review the requirements with the Program Specialist to ensure they complete the assessments in the required time frame |
08/26/2025
| Implemented |
| 2380.21(l) | There was no record of documentation that Individual #1 had a quarterly conversation during the quarterly time frame of July 2024 through September 2024 regarding their choice on preferred community participation activities. | An individual has the right to make choices and accept risks. | Director will review with the program Specialist to ensure that a conversation occurs on a quarterly basis about choices and risks, and to document these conversations every quarterly. |
08/26/2025
| Implemented |
| 2380.181(f) | Individual #1's Individual Support Plan meeting was held on 3/31/25 and their annual assessment was sent by the program specialist to the team on 3/4/25. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Director will ensure by meetings with the Program Specialist that all assessments are submitted to the SC's in the required timeframes to ensure compliance |
08/26/2025
| Implemented |