| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Individual #1 had fire safety training on 11/10/2016. He didn't have it again until 1/2/2018, which exceeds the annual requirement. Individual #2 had fire safety training on 11/23/2016. She didn't have it again until 1/2/2018, which exceeds the annual requirement. Individual #4 and Individual #6 had fire safety training on 11/10/2016. They didn't have it again until 12/26/2017, which exceeds the annual requirement.
Staff #1 had fire safety training on 11/11/2016. He didn't have it again until 12/26/2017, which exceeds the annual requirement. Staff #2 had fire safety training on 11/10/2016. She didn't have it again until 12/26/2017, which exceeds the annual requirement. | Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept. | Program Director will ensure that everyone has Fire Safety within a year. Partners In Progress goal is to have all fire safety training happen in October. |
10/31/2018
| Implemented |
| 2390.151(a) | Individual #3 was admitted on 11/20/2017 and should have had an initial assessment completed by 1/20/2018. As of the date of this inspection, an initial assessment has not been completed which exceeds the 60 day requirement. Individual #5 was admitted on 3/6/2017. He didn't have an initial assessment completed until 8/15/2017, which exceeds the 60 day requirement. | Each client 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. | Program Director will reteach Program Specialists regarding the regulation for intitial assessments for individuals who are new to the facility, and also remind them that there is no 15 day grace period. |
02/16/2018
| Implemented |
| 2390.151(f) | Individual #6 had an ISP meeting on 6/8/2017. Her assessment wasn't provided to her team 30 days prior to her meeting. It was completed & sent on 5/16/2017. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | The Program Director will reteach Program Specialists about the regulation being sending the assessment 30 days before the ISP meeting. |
02/16/2018
| Implemented |