| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.173(1)(ii) | Individual #1's record did not include the individual's hair color and identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | POC - The Individual Personal Information Document was modified to include a red asterisk for all required fields. |
07/18/2022
| Implemented |
| 2380.181(a) | Individual #1 had an assessment completed 4/27/2021 and again on 5/25/2022. This exceeds the annual 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. | P0C - Program Specialist Task document has been modified to reflect the Annual Assessment due date be performed at least 30 days prior to the scheduled ISP meeting. |
08/01/2022
| Implemented |
| 2380.38(b)(4) | Direct Services Worker #1, date of hire 5/26/2022, did not complete the following training topic during orientation: Recognizing and Reporting Incidents. Direct Services Worker #2, date of hire 5/23/2022, did not complete the following training topic during orientation: Recognizing and Reporting Incidents. | The orientation must encompass the following areas: Recognizing and reporting incident. | POC: The New Hire training syllabus has been modified to include the Recognizing and Reporting of Incidents within the 1st 30 days of hire. |
08/01/2022
| Implemented |
| 2380.181(f) | Individual #1's assessment was provided to the individual plan team members on 6/9/2022 and the plan meeting was held on 6/1/2022. The assessment was not provided at least 30 calendar days prior to the individual plan meeting. Individual #2's assessment was sent to the plan team 5/9/2022. The plan meeting was held on 5/9/2022. The assessment was not provided at least 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | P0C - Program Specialist Task document has been modified to reflect the Annual Assessment due date be performed and mailed to client team at least 30 days prior to the scheduled ISP meeting. |
08/01/2022
| Implemented |