| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.104(4) | Individual #8, Individual #9's, and Individual #10's record does not include medical information pertinent to diagnose or treat in the event of an emergency. | Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency. | Program Specialist will utilize revised emergency medical form and update individual #8, #9 and #10's records to comply with 2390.104(4) by 8/17/23. Program specialists will review cases to ensure 2390.104(4) is addressed in each record by 9/1/23.
Attachment:
Revised emergency medical #8 Johnstown
Revised emergency medical #9 Johnstown
Revised emergency medical #10 Johnstown |
09/01/2023
| Implemented |
| 2390.151(e)(1) | Individual #1's most recent assessment dated 11/18/22 did not identify any of their strengths. Individual #11's most current assessment completed on 5/24/23 does not identify any of their strengths. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | Program Specialist will amend individual #1's assessment to identify their strengths by 8/17/23 and distribute to ISP team members. Program Specialist will amend individual #11's assessment to identify their strengths by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)1 is addressed in its entirety by 9/1/23.
Attachment:
Revised assessment #1 Johnstown
Revised assessment #11 Johnstown
Johnstown training sheet |
09/01/2023
| Implemented |
| 2390.151(e)(3)(iv) | Individual #1's most recent assessment dated 11/18/22 does not address their personal needs with or without assistance. This section only addressed the individual's ability with finances. | The assessment must include the following information: The client's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Program Specialist will amend individual #1's assessment to identify their personal needs with or without assistance by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)(3)iv is addressed in its entirety by 9/1/23.
Attachment:
Revised assessment #1 Johnstown
Johnstown training sheet |
09/01/2023
| Implemented |
| 2390.151(e)(4) | Individual #5's most recent assessment dated 5/6/23 indicates they need "moderate" supervision at the program while the ISP indicates the individual needs line of sight of supervision at the program. | The assessment must include the following information: The client's need for supervision. | Program Specialist will amend individual #5's assessment to identify their need for supervision by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)4 is addressed accurately as it is in the ISP by 9/1/23.
Attachment:
Revised assessment #5 Johnstown
Johnstown training sheet |
09/01/2023
| Implemented |
| 2390.151(f) | Individual #7's most recent assessment completed on 6/10/23 was not provided to the SC and Team 30 days prior to the ISP meeting. The team meeting was 7/14/23. There was no documentation the assessment was provided to the team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | Program Specialist will notate date sent and distribute individual #7's assessment by 8/17/23 to ISP team members. Program Specialists will review cases to ensure 2390.151(f) is addressed in its entirety by 9/1/23.
Attachment:
Revised assessment #7 Johnstown
Johnstown Training sheet |
09/01/2023
| Implemented |
| 2390.153(a)(1) | Individual #6's most recent ISP team meeting held on 7/24/23 did not include Individual #6. | The individual plan shall be developed by an interdisciplinary team, including the following: The client. | Program specialists will review cases to ensure 2390.153(a)1 is completed on each signature page by 9/1/23.
Attachment:
Johnstown Training sheet
CCABH signature page |
09/01/2023
| Implemented |
| 2390.153(b) | Individual #11's most recent ISP team meeting held on 8/17/22 only included two team members and Individual #11. | At least three members of the individual plan team, in addition to the client and persons designated by the client, shall be present at a meeting at which the individual plan is developed revised. | Program specialists will review cases to ensure 2390.153(b) is met on each signature page by 9/1/23.
Attachment:
Johnstown Training sheet
CCABH signature page |
09/01/2023
| Implemented |
| 2390.153(a)(2) | Individual #4, Individual #7, and Individual #11's ISP team meeting did not include any of their designated persons/family. | The individual plan shall be developed by an interdisciplinary team, including the following: Persons designated by the client.
| Program specialists will review cases to ensure 2390.153(a)(2) is met on each signature page by 9/1/23.
Attachment:
Johnstown Training sheet
CCABH signature page |
09/01/2023
| Implemented |
| 2390.153(a)(3) | Individual #4, Individual #6, and Individual #11's most recent ISP team meetings held did not include any of their direct care workers. | The individual plan shall be developed by an interdisciplinary team, including the following: The client's direct care staff persons.
| Program specialists will review cases to ensure 2390.153(a)3 is met on each signature page by 9/1/23.
Attachment:
Johnstown Training sheet
CCABH signature page |
09/01/2023
| Implemented |