| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.33(b)(1) | Program specialists did not complete assessments prior to 5/12/15. Other direct service workers who did not have program specialist qualifications were completing assessments. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The program specialist will be responsible for completing the ISP reviews in addition to coordinating and completing the assessment. They have received instruction in this area (see Attachment 1). |
08/18/2015
| Implemented |
| 2390.33(b)(10) | The program specialist for Individual #2 did not review, sign, and date the monthly documentation of Individual #2's participation and progress towards outcomes for the months of May, July, August, and September of 2014. The program specialist for Individual #1 did not review, sign, and date the monthly documentation for October and November 2014. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of a client's participation and progress toward outcomes. | The program specialists are responsible for reviewing, signing, and dating monthly documentation of an individual¿s participation and progress towards outcomes. Program Specialists have been retrained in this area (Attachment 1). Attached are the most recent completed monthly reviews for Individuals #1 and #2 (see attachments 22 and 23). |
08/18/2015
| Implemented |
| 2390.40(a) | Staff #1's date of contact with individuals was on 7/14/14 and she was not oriented to job responsibilities and daily operations of the facility until 7/14/14. | A facility shall provide orientation for staff relevant to their appointed positions. Staff shall be instructed in the daily operation of the facility and policies and procedures of the agency. | Our protocol is for supervisors to review job responsibilities and daily operations on the first day they begin working in the program. This is done prior to them working with individuals. Staff #1 has attested she was trained in her job responsibilities, and daily operations prior to working with any individuals (see attachment 22). Policies and Procedures are reviewed in session 6 of the 2 week orientation training (see attachment 23). |
08/18/2015
| Implemented |
| 2390.40(b) | Staff #2 only had 22.25 hours of annual human services of training. Staff #4 only had 21.5 hours of annual human services training. | Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually. | Staff are responsible to schedule and obtain 24 hours of training yearly. Staff were retrained in this area and are aware they must have at least 24 hours of training relevant to vocational or human services annually. That certain trainings were not able to be used toward the 24 hours of required training was unknown to us. Our Training Department has revised its tracking system to count only the training hours able to be used toward the 24 hours required (attachment 21). |
08/18/2015
| Implemented |
| 2390.87 | Individual #1's date of entry was 3/10/14 and he did not receive fire safety training until 8/14/14. | 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 Specialists are responsible for completing the intake process with individuals. They will be retrained in the completion of the orientation checklist on the date of admission (Attachment 1). An orientation checklist is attached (see attachment 20) for a new individual. |
08/18/2015
| Implemented |
| 2390.104(1) | Emergency contact information was not in the record for Individual #3. | Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency. | Program Specialists are responsible to ensure all information on the face sheet is accurate and up to date. Program Specialists have been retrained in ensuring the face sheet is up to date and includes the emergency contact person¿s name, address, and phone number. An updated face sheet for Individual #3 is attached (see attachment 18.) A face sheet for a new individual with the emergency contact information is also enclosed (see attachment #12). A total record review will be completed. All necessary corrections will be made to face sheets. |
10/30/2015
| Implemented |
| 2390.112(b) | Individual #7's date of entry was 2/2/15 and she did not receive written information outlining working hours, benefits, leave policy, civil rights policies and procedures, and grievance procedures until 5/15/15. | Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. | Program Specialists are responsible for completing the intake process with individuals. They will be retrained in the completion of the orientation checklist on the date of admission (Attachment 1). An orientation checklist is attached (see attachment 20) for a new individual. |
08/18/2015
| Implemented |
| 2390.124(1) | The place of birth was not in the record for Individual #4. | Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge. | Program Specialists are responsible to ensure accurate information is in each individual¿s record. Program Specialists have been retrained in this information (Attachment 1). Attached is the face sheet for another individual (see attachment 18).
A total record review will be completed. Face Sheets will be checked to ensure that they contain the name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge.
|
10/30/2015
| Implemented |
| 2390.124(12) | The assessment for Individual #3 contained information written within that stated he could evacuate independently but also that he couldn't evacuate independently. Individual #3's assessment also stated that he could identify heat sources but also written that he couldn't identify heat sources. The identification sheet and Individual Support Plan (ISP) for Individual #1 stated that they had a diagnosis of Intermitten Explosive Disorder. However his ISP also said that he had no mental health dianosis. The ISP for Individual #5 stated he was taking Ability for siezures. However Individual #5's identification sheet and physical stated he took Ability for Intermitten Explosive Disorder. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Program Specialists are responsible to there is no content discrepancy between ISP¿s, ISP Reviews and Assessments. Program Specialists have been retrained in this information (Attachment 1). Attached is the assessment addendum for Individual #3 (see attachment 16). Individual #1 is no longer taking medication for IED. Attached is his updated identification sheet and the excerpt from his current ISP stating that he does not take medications for mental health issues (see attachment 19). Individual #5 is no longer in the program.
A total record review will be completed to ensure there is no content discrepancy in the ISP, Assessment, annual update or revision.
|
10/30/2015
| Implemented |
| 2390.151(a) | Individual #7's date of entry was 2/2/15 and there was still no initial assessment when licensing was there on 5/26/15. Individual #1 had an assessment on 5/8/14 and didn't have another assessment completed yet. Individual #1 needed their assessment completed by 5/8/15. | 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 Specialists are responsible for completing assessments within 60 days of admission, and annually thereafter. PS¿s have been retrained in this information (see attachment 1). Enclosed is the face sheet with the start date for a new individual, the cover letter and the first page of the new individual¿s assessment (see attachment 12). Also enclosed are the cover sheets of an individual¿s assessments showing that the most recent was done within the regulatory timeframe (attachment 12 A).
A total record review will be completed. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
10/30/2015
| Implemented |
| 2390.151(e)(2) | The assessment for Individual #2 did not include likes, dislikes, and interests. | The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also is an assessment addendum to Individual¿s #2 assessment adding this information (see attachment 13). In addition, a recently completed assessment with correct information is attached (see attachment 14).
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(5) | The assessments for Individuals #2, #5, and #6 did not include their ability to self-administer medications. | The assessment must include the following information: The client's ability to self-administer medications. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also are assessment addendums to Individuals #2 and 6 assessments adding this information (see attachment 13 and 15). In addition, a recently completed assessment with correct information is attached (see attachment 14). Individual #5 is no longer in the program.
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(12) | The assessments for Individuals #2, #5, and #6 did not include recommendations for specific areas of vocational training or placement. | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also are assessment addendums to Individuals #2 and 6 assessments adding this information (see attachments 13 and 15). In addition, a recently completed assessment with correct information is enclosed (see attachment 14). Individual #5 is no longer in the program.
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(13)(i) | The assessments for Individuals #2, #3, #4, and #5 did not include their progress over 365 days in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | The individuals listed have this information completed. The individuals missing the information are Individuals #4 and 5. Both of these individuals are no longer in the program. The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1).
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(13(ii) | The assessments for Individuals #2 and #3 did not include their progress over 365 days in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see attachment 1). Attached also are assessment addendums to Individuals #¿s 2 and 3 assessment adding this information (see attachments 13 and 16). In addition, a recently completed assessment with correct information is attached (see attachment 14).
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(13)(iii) | The assessments for Individuals #2, #3, and #5 did not include their progress over 365 days in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also are assessment addendums to Individuals #¿s 2 and 3 assessment adding this information (see attachments 13 and 16). Individual #5 is no longer in the program. In addition, a recently completed assessment with correct information is attached (see attachment 14).
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(13(iv) | The assessments for Individuals #2, #3, and #5 did not include their progress over 365 days in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | : The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also are assessment addendums to Individuals #¿s 2 and 3 assessment adding this information (see attachments 13 and 16). Individual #5 is no longer in the program. In addition, a recently completed assessment with correct information is attached (see attachment 14).
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.151(e)(13)(v) | The assessments for Individuals #2 and #3 did not include their progress over 365 days in vocational skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills. | The Program Specialists are responsible for ensuring the assessments have accurate and thorough information according to regulatory guidelines. They have been retrained in this information (see Attachment 1). Attached also are assessment addendums to Individuals #¿s 2 and 3 assessment adding this information (See attachments 13 and 16). In addition, a recently completed assessment with correct information is attached (see attachment 14). A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members. |
10/30/2015
| Implemented |
| 2390.151(f) | The program specialist for Individual #4 provided Individual #4's assessment to team members on 1/16/15. However, Individual #4's Individual Support Plan meeting was on 2/12/15, less than 30 days after the assessment was sent. | 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). | Program Specialists are responsible to ensure assessments are distributed to team members w/in the regulatory timeframe. Program Specialists have been retrained in this information (Attachment 1). A recently completed assessment sent out w/in the appropriate time frame, and the letter from the plan lead stating the date of the meeting are attached (see attachments 14 and 17). Individual #4 is no longer in the program.
A total record review will be completed. Assessment Addendums for areas that need corrected will be completed and distributed to team members.
|
10/30/2015
| Implemented |
| 2390.153(1) | The Individual Support Plan for Individual #7 did not contain an expected outcome chosen by the client and team members in relation to the vocational facility. The ISP outcome for Vocational for Individual #7 stated that an outcome needed to be established. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team. | This is an error. Individual #7 does have an outcome summary in his ISP which was printed on 5/14/15. The services are also listed in the service detail section of the ISP (see attachment 7). |
08/18/2015
| Implemented |
| 2390.153(5) | Individual #1 is prescribed Abilify and Escitalophram for anxiety and intermitten explosive disorder. Individual #1 did not have a protocol to address the social, emotional and environmental needs of their diagnosed psychiatric illness. | A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Program Specialists are responsible to ensure all individuals on their caseload have a Support Plan if anyone take medication for a psychiatric illness and have been retrained in this information (see Attachment 1). Individual #1 no longer takes psychotropic medications. Therefore, a support plan is not necessary.
A total record review will be completed. A support plan will be implemented for any individual who receives medication for a psychiatric diagnosis who does not have one.
|
10/30/2015
| Implemented |
| 2390.153(7)(i) | The Individual Support Plans (ISPs) for Individuals #1 and #6 did not contain an assessment of their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming. | Program Specialists are responsible to ensure all individuals on their caseload have in their ISP¿s the potential to advance in vocational programming. They have been retrained in this information (see Attachment 1). There is an error as Individual #1¿s ISP does include this information. The current ISP page which states this is included (see attachment 8). Enclosed is correspondence to Individual #6¿s Supports Coordinator to add this information to their ISP¿s. (see attachment 9).
A total record review will be completed. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
10/30/2015
| Implemented |
| 2390.153(7)(ii) | The Individual Support Plans (ISPs) for Individuals #1 and #6 did not contain an assessment of their potential to advance in community-integrated employment. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment. | Program Specialists are responsible to ensure all individuals on their caseload have in their ISP¿s the potential to advance in community integrated employment. They have been retrained in this information (see Attachment 1). Enclosed is correspondence to Individuals #1 and 6 Supports Coordinators to add this information to their ISP¿s. (see attachments 10 and 11).
A total record review will be completed. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
10/30/2015
| Implemented |
| 2390.156(a) | Program specialists were not completing Individual Support Plan (ISP) reviews prior to 5/12/15. Other direct service workers who were did not have program specialist qualifications were completing the ISP reviews prior to 5/12/15. Individual #3 only had an ISP review completed on 5/22/14 and 9/17/14. No other reviews were completed for Individual #3 since last licensing year. ISP reviews for Individual #4 were completed more than 3 months apart; 5/22/14, 9/8/14, and 2/19/15. Individual #1 had and ISP review completed on 2/12/15 and was due for their next review on 5/27/15. An ISP review for Individual #1 was not completed before the end of licensing on 5/27/15. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | : Program Specialists are responsible to ensure ISP Reviews are completed w/in the regulatory time frame. Attached are ISP Reviews for an individual that have followed correct time frames ¿ both the current ISP Review and the previous ISP Review (see attachment 3). In addition, ISP Quarterly Reviews for Individual 3, both the current ISP Review and the previous review are attached (see attachment 4). Individual #1 is on a leave of absence and the date to return has not been determined. Individual #4 no longer attends the program.
Program Specialists will receive training in the regulatory timeline for completing and distributing ISP Reviews (see attachment 1). Also, Program Specialists will utilize charts for due dates of ISP Reviews for all individuals on their case load (attachment 2).
A total record review will be completed. ISP Reviews that are not in compliance will be corrected at the next ISP Review date.
|
10/30/2015
| Implemented |
| 2390.156(c)(1) | The Individual Support Plan (ISP) review for Individual #1 that was completed on 6/6/14 did not review monthly documentation of their participation and progress during the prior 3 months towards their ISP outcome. | The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter. | : Program Specialists are responsible for completing the ISP review and have been retrained in thoroughness and content of the review (see attachment 1). Another ISP review with the correct information is attached. The prior and most recent ISP Reviews for Individual #1 will be completed on 8/19/15 and will be reviewed with him when he returns from his medical leave. This will be forwarded by the target date.
A total record review will be completed. ISP Reviews that are not in compliance will be corrected at the next ISP Review date.
|
10/30/2015
| Implemented |
| 2390.156(c)(2) | Individual Support Plan (ISP) reviews for Individuals #1, #2, #4, and #5 did not include a review of their social, emotional, environmental plans or their supervision plans. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Program Specialists are responsible for completing the ISP Review and have been retrained in thoroughness and content of the review (see attachment 1). Individual #1 is no longer taking psychotropic medications. The program specialist was notified on 7/29/15 of this change. Therefore, a social, emotional, environmental plan is not necessary. Attached is the most recent ISP Review for Individual #2 which includes a review of the social, emotional, environmental plan (see attachment 6). Individuals #4 and 5 are no longer in the program.
A total record review will be completed. ISP Reviews that are not in compliance will be corrected at the next ISP Review date.
|
10/30/2015
| Implemented |
| 2390.156(d) | Individual #4's Individual Support Plan (ISP) review was completed on 5/22/14 but sent to team members on 5/19/14, before it was completed with the individual. Individual #3's ISP review was completed with the individual on 12/15/14 but sent to team members on 9/7/14. Individual #2's ISP review was completed with her on 4/2/15 but sent to team members on 3/31/15. Individual #1's ISP reivew was completed on 9/12/14 but sent out on 9/9/14. The ISP reviews for Individual #1 that were completed on 11/19/14 and 2/12/15 did not have a date on the letter stating that they were sent to team members. | The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Program Specialists are responsible for distribution of ISP Reviews to team members and have been retrained in the regulatory timelines (see Attachment 1). Enclosed is an ISP Review that has been sent out w/in regulatory guidelines (see attachment 3). The most recent ISP review for Individual #2 were sent out w/in regulatory guidelines (see attachment 6). The most recent ISP Review for Individual #1 will be forwarded by the target date (see attachment 5). Individuals #3 and #4 are no longer in the program.
A total record review will be completed. ISP Reviews that are not in compliance will be corrected at the next ISP Review date.
|
10/30/2015
| Implemented |