| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.33(b)(18) | Staff #2 is a 1:1 staffing support aid for Individual #3. There was no documentation to support that Staff #2 was trained on Individual #3's Individual Support Plan (ISP), assessment, or other health maintenance needs. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each client. | Program Specialist/Director will ensure that ISP training certification documentation is individual-specific and provided prior to providing service, annually thereafter and/or if any updates are made to the ISP. |
12/22/2017
| Implemented |
| 2390.40(a) | Staff #1 was hired on 2/3/17 and she did not receive training relevant to her program specialist responsibilities or daily operations of the facility. | 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. | Training certification form was adjusted to outline specific areas covered, including job specific duties, during on-site orientation training conducted the date of hire. |
12/08/2017
| Implemented |
| 2390.40(b) | Staff #2 only had 16.9 hours of training in the 2016 training year. | Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually. | Director will ensure that all staff, full time, part-time or on call, shall receive 24 hours of training between the period of January 1st through December 31st annually. |
12/31/2017
| Implemented |
| 2390.61 | Individual #1's locker was bent, allowing the bottom metal corner to stick out causing a hazard. Two metal outlets are sticking out of the floor in the dining area where individuals walk, creating a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | Tape was applied to the locker door to prevent hazard. Replacement door is currently on order and expected to arrive 12/15/17. Metal outlets were removed. Maintenance department is currently in the process of filing the extension poles more flush so the areas may be tiled. Tripping hazard as been eliminated. |
12/15/2017
| Implemented |
| 2390.82(a) | The emergency evacuation plan did not include the emergency shelter location. | Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas. | Emergency shelter agreement is in place with Nazarene Baptist Church, located directly across the street from the facility. Emergency evacuation plan was updated to include that information. |
12/08/2017
| Implemented |
| 2390.87 | Staff #2 had fire safety training on 12/14/15 and not again until 12/20/16, outside of the annual timeframe. | 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. | Director will ensure timely update of annually required training for all staff. |
12/20/2017
| Implemented |
| 2390.103 | The emergency medical plan did not include the hospital or source of health care that will be used in an emergency. | A facility shall have a written emergency medical plan listing the following:(1)The hospital or source of health care that will be used in an emergency. (2) The method of transportation to be used.(3) Written consent from the client, parent or guardian for emergency medical treatment.(4) The staffing plan during the emergency. | Emergency medical plan was updated in include the hospital to be used in the event of an emergency. |
12/08/2017
| Implemented |
| 2390.112(b) | - Individual #2's record did not indicate if he/she received written information on his/her work hours, benefits, leave, and policy and procedures. A form in his/her to indicate Individual #2 received a copy of the program handbook was not marked to indicate that Individual #2 received a copy. The vocational habilitation handbook did not include information regarding individuals' benefits and policy and procedures. | 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. | Participant handbook was updated to include work hours, benefits, and leave. The check box was completed indicating her receipt. The form was already signed. |
12/08/2017
| Implemented |
| 2390.123 | Individual record information and attendance forms for all individuals were left unlocked and accessible on the staff's desks throughout the facility. | Information in the client records shall be kept confidential. Client records shall be kept locked when unattended. | Director will ensure that all PHA that is not being worked on by staff is locked in a file cabinet and that staff lock unattended office doors. |
12/08/2017
| Implemented |
| 2390.151(c) | Individual #1's 6/28/17 assessment did not indicate if it was based off of interviews, progress notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | " and to complete the assessment" was added to "The Individual program Planning Guide (IPPG), notes, and observational data were used to determine the individual's current level of functioning and to identify strengths and needs" to bring statement in line with regulatory requirements. Annual assessment format will adjusted to provide prompters to ensure all elements related to assessment tools and processes utilized for evaluation.. Addendums will be completed for all assessments that do not contain required information relative to assessment tools and processes utilized for evaluation. |
12/15/2017
| Implemented |
| 2390.151(e)(5) | Individual #1's 6/28/17 assessment did not include his/her ability to self-administer medication. | The assessment must include the following information: The client's ability to self-administer medications. | Annual assessment format will adjusted to provide prompters to ensure all elements related to each individual's ability to self-administer medication is appropriately addressed. Addendums will be completed for all assessments that do not contain required information relative to each individual's ability to self-administer medication. |
12/15/2017
| Implemented |
| 2390.151(e)(7) | Individual #1's 6/28/17 assessment did not include his/her knowledge of heat sources and ability to move away. | The assessment must include the following information: The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Annual assessment format will adjusted to provide prompters to ensure all elements related to each individual's knowledge of heat sources and their ability to move away is appropriately addressed. Addendums will be completed for all assessments that do not contain required information relative to each individual's knowledge of heat sources. |
12/22/2017
| Implemented |
| 2390.151(e)(12) | Individual #1's 6/28/17 assessment did not include recommendations for specific areas of training, services or programming needs for Individual #1. | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | Annual assessment format will adjusted to provide prompters to ensure all elements related to specific areas of vocational training, services or programming is appropriately addressed. Addendums will be completed for all assessments that do not contain required information relative to recommendations for specific areas of vocational, training or programming needs. |
12/22/2017
| Implemented |
| 2390.151(e)(13(ii) | Individual #1's 6/28/17 assessment did not include progress in motor and communication skills. The 2017 and 2016 assessments were verbatim. | 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. | Annual assessments will include specific information obtained through use of progress notes, IPPG and observational data to appropriately and accurately reflect progress and current levels of functioning in the areas of motor and communication skills. Addendums will be completed for all assessments that do not contain required information. |
12/22/2017
| Implemented |
| 2390.151(e)(13)(iii) | Individual #1's 6/28/17 assessment did not include progress in personal adjustment skills. The 2017 and 2016 assessments were verbatim. | 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. | Annual assessments will include specific information, obtained from progress notes and observational data, to accurately reflect progress in the area of personal adjustment skills. Addendums will be completed for all assessments that do not include information relative to personal adjustment skills. |
12/22/2017
| Implemented |
| 2390.153(7)(i) | Individual #1's Individual Support Plan (ISP) did not include his/her 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. | Annual assessment format will adjusted to provide prompters to ensure all elements related to potential advancement in vocational programming. Addendums will be completed for all assessments that do not contain required information relative to the potential for advancement in vocational programming. |
12/15/2017
| Implemented |
| 2390.153(7)(ii) | Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in community competitive-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. | Annual assessment format will adjusted to provide prompters to ensure all elements related to potential advancement in community-competitive employment. Addendums will be completed for all assessments that do not contain required information relative to the potential for advancement in community-competitive employment. |
12/15/2017
| Implemented |
| 2390.154(a)(1)(iii) | A direct support staff from the vocational facility did not attend or assist in Individual #1's annual Individual Support Plan (ISP) meeting held on 9/13/17. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2390.156 (relating to ISP review and revision). A plan team must include as its members the following: A direct service worker who works with the client from each provider delivering a service to the client. | Direct care staff will attend ISP meetings held on site. In the event that ISP meetings are held off site or staff/participant ratios do not allow for direct staff attendance, a written report, reflecting direct staff's summary of participant performance and progress will be submitted for review. |
12/08/2017
| Implemented |
| 2390.156(a) | Individual #1's had an Individual Support Plan (ISP) review completed on 8/10/16 and not again until 2/26/17 | 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. | Along with Outlook reminders for timely completion of ISP reviews, Director will maintain an excel spreadsheet of scheduled dates for ISP reviews.
Director will ensure coverage of case maintenance in the event of Program Specialist absences and vacancies. |
12/01/2017
| Implemented |