Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2390.83(a) | The fire alarm was inoperable at the time of inspection. | There shall be an operable fire alarm that is audible throughout the facility. | Smoke detectors were purchased and placed in the program area and lunchroom. They will remain in use as a precaution, in the event that another issue with the upstairs tenants would cause the wired fire alarm to malfunction. The wired fire alarm was successfully put back into service on 7/15/22, after the damage from the issue was repaired. |
07/15/2022
| Implemented |
2390.49(c)(3) | Staff #1 and Staff#2 did not receive annual training in training year 2021 on Client rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Client rights. | The annual training plan was updated to ensure that Individual Rights training is identified as a required training for all agency provider staff. Each staff was sent a copy of the updated training plan. |
05/20/2022
| Implemented |
2390.49(c)(5) | Staff #2 did not receive annual training in training year 2021 on the safe and appropriate use of behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with a client. | The annual training plan was updated to clearly identify Positive approaches- restrictive procedures as a required training for all agency provider staff. Each staff was sent a copy of the updated training plan. |
07/19/2022
| Implemented |