| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(a) | Staff #1's first date of contact with individuals was 8/30/17 and she did not receive training on her job description or orientation to the facility until 8/30/17. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | The licensed facility in this chapter shall provide training on staff persons orientation on the job description prior to working with individuals. The licensed facility's corporate headquarters will provide orientation on the job description during the staff persons initial hire orientation at the corporate headquarters prior to working with individuals. The Facility Director trained staff responsible for orientation for this licensed facility on 1/26/18. The procedure for headquarters orientation was updated 2/6/18. |
02/06/2018
| Implemented |
| 2380.53(a) | Eye wash and antiseptic that contained labels to contact poison control center if ingested were found unlocked and accessible in the first aid kit in the first aid room. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Poisonous materials (eye wash and antiseptic) shall be kept locked within the first aid kit in the first aid room. The Facility Director ordered (on 1/30/18) a locked box to store the eye wash and antiseptic (items that contained labels to contact poison control). The Facility Director trained safety committee staff on citation 2380.53.a related to first aide items containing labels to contact poison control shall be locked and made inaccessible to individuals in 2380 program; training occurred on 1/26/18. |
02/06/2018
| Implemented |
| 2380.55(a) | The fish tank in the entryway area was filled with murky water. | Clean and sanitary conditions shall be maintained in the facility. | The licensed facility in this chapter needs to maintain clean and sanitary conditions. The Facility Director (on 1/26/18) trained 2380 (ATF) staff on citation 2380.55.a and checked on the status of the cleaned fish tank. The fish tank was cleaned (1/26/18). |
01/26/2018
| Implemented |
| 2380.58(a) | The refrigerator/freezer in the large program room was not equipped with handles to open the doors. The men's bathroom was missing baseboard near the toilet and the drywall in the corner of the room by the toilet appeared as if it had water damage and was in need of repair. The toilet tank lid was zip-tied shut. The wall to the right of the doorway, immediately entering the large program room, contained approximately 2 feet of black scuff marks and was missing a chunk of drywall. | Floors, walls, ceilings and other surfaces shall be in good repair. | The floors, walls, ceilings and other surfaces for the licensed facility in this chapter need to be in good repair. The Facility director communicated with the licensed facility maintenance department (on 1/30/18) to schedule maintenance for the refrigerator/freezer handles to be installed on the doors, men's bathroom baseboard, drywall in the men's bathroom, removal of the zip tie on the toilet tank in the men's bathroom, repair on the wall/drywall in the large program room. The maintenance department (on 2/6/18) scheduled to repair cited items in accordance to 2380.58.a. |
02/06/2018
| Implemented |
| 2380.83(a) | The emergency evacuation plan did not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | There shall be a written emergency evacuation procedures that include: the individual and staff responsibilities. The emergency evacuation plan for the facility licensed in this chapter was updated on 1/26/18 by the Facility Director to include the individual(s) responsibilities. The responsibilities of the individuals will be to evacuate the facility in the event of an emergency in an orderly and timely manner, as well as, take instruction from their group supervisor. The Facility Director trained facility staff responsibility for evacuation procedures on 1/26/18. The emergency evacuation plan was updated and staff retrained on the emergency evacuation plan on 1/26/18. |
02/06/2018
| Implemented |
| 2380.89(h) | A fire alarm was not set off during the fire drill held on 8/22/17. The fire drill log indicated, which was verified by staff, that staff used a whistle to signal the fire drill. | A fire alarm shall be set off during each fire drill. | A fire alarm will be set off during each fire drill. A fire alarm must be held at least month and includes setting off the alarm. A whistle drill to signal a fire drill is a best practice; however, an alarm drill must be set off within the same month of the whistle drill. The Facility Director will run an alarmed fire drill at least once a month and record each drill on the fire drill log with results accordingly. The Facility Director was made aware and trained on citation related to 2380.89.h by the licensing inspector on 1/17/18. Training related to 2380.89.h occurred by the Facility Director to staff (Asst. Director and Production Manager) on 1/29/18 specific to running a fire drill with alarm at least once a month. |
01/30/2018
| Implemented |
| 2380.111(c)(3) | Individual #2's 2/28/17 physical examination indicated that his last diphtheria and tetanus was administered on 2/19/07, passed the every 10 year regulation requirement. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical examination will be updated to include: immunizations as recommended by the US Public Health and Centers for Disease Control. The program contacted individual #2's parents 1/26/18 to inform them of the following immunizations (diphtheria and tetanus) which were needed 2/2017. The program specialist will obtain (1/30/18) a date of appointment for individual #2 for the required immunizations. The program specialist was trained in the area of physical examines and 10 year regulation requirement (2380.111.c.3).
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.111(c)(9) | Individual #1 has seasonal allergies however his/her 2/23/17 physical examination did not indicate seasonal allergies. | The physical examination shall include: Allergies or contraindicated medication. | The physical examine will include: allergies and contraindicated medication. The program specialist communicated with individual #1's parents on 1/31/18 to obtain an appointment date in order for the physician to update the physical examination form to include individual #1's seasonal allergies in the allergies section of the physical examination form. The program specialist was trained on 1/30/18 on 2380.111.c.9 relative to the allergy section being completed during the physical examine.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/06/2018
| Implemented |
| 2380.115(3) | The written emergency medical plan did not include the staffing plan during the emergency. | The facility shall have a written emergency medical plan listing the following: An emergency staffing plan. | The facility shall have a written emergency medical plan listing the following: emergency staffing plan. The emergency medical plan for the licensed facility in this chapter was updated by the Facility Director on 2/2/18) to include the following: an emergency staffing plan. |
02/02/2018
| Implemented |
| 2380.128(e) | Staff #1's initial medication administration training information did not contain documentation of her 4 observations; the practicum summary was the only document completed. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | Documentation of medications administration training for trainers and staff person shall be kept for each person trained in medication administration. Staff #1's medication administration training was updated (on 1/29/18 by the medication administration trainer, Asst. Director) to include the documentation of her 4 observations (1 on each sheet).
The medication administration trainer (Assistant Director) was retrained on this procedure on 1/29/18. |
02/02/2018
| Implemented |
| 2380.173(9) | Individual #1's 7/28/17 assessment indicated he/she takes medications for anxiety and seizures. His/Her Individual Support Plan (ISP) only indicated medication he/she takes for seizures and congestion. His/Her ISP indicated he/she needs assistance with all daily living skills except eating. His/her ISP also indicated meals don't need prepared a certain way, but must be chopped. His/Her ISP reviews indicated that staff have to hold his/her hand when he/she walks so he/she won't fall however his/her 7/28/17 assessment did not indicate this need. His/Her ISP only indicated staff must hold his/her hand in the mall and stores or he/she may run into the stores or run away. The staffing ratio recorded in his/her 7/28/17 assessment indicated the need for 1:6 group ratio however the ISP indicated the staffing ratio at program should be 1:3. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Each individual's record must include the following: content of discrepancies in the ISP. The individual's (individual #1) record was updated (2/2/18)by the program specialist to include any content discrepancies in the ISP. The program specialist reported content discrepancies from individual #1's assessment to the supports coordinator (email) (2/2/18) in order to update the ISP in the areas of medication, supervision, meal prep, assistance with ambulation/motor, and ratio. The program specialist was trained on 1/30/18 on reporting content discrepancies (2380.173.9)
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(1) | Individual #1's 7/28/17 assessment and Individual #2's 2/20/17 assessment did not include his/her strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment will include the following information: strengths, needs, and preferences. The assessment for individual #1 and individual #2 was updated (2/2/18) and forwarded to the supports coordinators .
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(4) | Individual #1's 7/28/17 assessment did not include his/her supervision needs at day program and in the community. His/Her assessment only indicated he/she needs monitoring at all times due to seizures and elopement. According to other documentation in his/her record, he/she needs to hold staff's hand in the community so Individual #1 will not elope. Individual #1's Individual Support Plan (ISP) also describes his/her need for physical support to walk around program due to having an unsteady gait. | The assessment must include the following information: The individual¿s need for supervision. | The assessment must including the following: the individual's need for supervision. The assessment was updated by the program specialist (2/2/18) to include the following; the individual's needs for supervision. The program specialist will update individual #1's assessment to indicate her supervision needs at the day program and while in the community with her day program. The program specialist will forward the updated assessment (2/2/18) to individual #1's supports coordinator for updates needed to individual #1's ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(6) | Individual #2's 2/20/17 assessment did not include his/her ability to use or avoid poisons. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must including the following information: the individual's ability to safely use or avoid poisonous materials. The assessment will be updated to include: the individual's (individual #2) ability to safely use or avoid poisonous materials. The program specialist will update the assessment (2/2/18) and submit the updated assessment to the respective support coordinator in order to update individual #2's ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(7) | Individual #1's 7/28/17 assessment did not include his/her knowledge of heat sources and if he/she will move away from heat sources quickly. According to his/her Individual Support Plan (ISP) Individual #1 will freeze up, not move or sit on the ground and require physical assistance to move. Individual #2's 2/20/17 assessment did not include his/her ability to move away from heat sources. | The assessment must include the following information: The individual¿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. | The assessment will be updated to include the individual's knowledge of heat sources and if the individual will move away from the heat source. The program specialist will update individual #1's assessment and individual #2's assessment (2/2/18) and forward the updated assessments to the respective supports coordinators in order for the ISP for individual #1 and individual #2 to be updated.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(10) | Individual #2's 2/20/17 assessment did not include his/her lifetime medical history. The lifetime medical history attached to the 2/20/17 assessment indicated it was updated on 2/27/17 and 4/26/17, after the completion of the assessment. The program specialist confirmed the lifetime medical history attached to the assessment was not completed and sent to team members with the 2/20/17 assessment. | The assessment must include the following information: A lifetime medical history. | The assessment will be updated to include the lifetime medical history for the individual. The program specialist updated individual #2's assessment to include the lifetime medical (2/2/18) and sent out to the supports coordinator for updates to individual #2's ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's 7/28/17 assessment did not include his/her current level of motor skills. Individual #2's 2/20/17 assessment did not include his/her current level and progress over the last year in motor 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 assessment will be updated to include the current level and progress of motor skills. The program specialist updated (2/2/18) individual #1's assessment to include her current level and progress towards motor skills. The program specials updated individual #2's assessment (2/2/18) to include his current level and progress towards motor skills. The assessment for individual #1 and the assessment for individual #2 were updated and forwarded to the respective supports coordinators in order to update the individuals' ISPs.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 7/28/17 assessment did not include his/her current level of recreation. Individual #2's 2/20/17 assessment did not include his/her current level and progress over the last year in recreation. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessment must include the following: current level and progress in the area of recreation. The assessment was updated to include current level and progress in the area of recreation. The program specialist updated individual #1's assessment (2/2/18) and updated individual #2's assessment (2/2/18) to address the area of recreation. The program specialist forwarded copies of the updated assessment for individual #1 and individual #2 to the supports coordinators for updates to the individual's ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 7/28/17 assessment did not include his/her community-integration. Individual #2's 2/20/17 assessment did not include his/her current level and progress over the last year in community-integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | The assessment was updated to address the area of community integration. The program specialist updated individual #1's assessment (2/2/18) to include her progress and growth in the area of community integration. The assessment for individual #1 was forwarded to her supports coordinator in order to update her ISP. The program specialist updated individual #2's assessment in include his progress and growth in the area of community integration (2/2/18). The updated assessment was forwarded to his supports coordinator in order to update his ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.181(f) | Individual #2's 2/20/17 assessment was sent on 2/20/17 but not 30 days prior to his/her Individual Support Plan (ISP) meeting that was held on 2/24/17. | 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). | The assessment must be sent out at 30 days prior to the ISP meeting date to the supports coordinator and the ISP team. The program specialist is submitting correspondence related to individual #2's assessment being under the 30 day timeline due to the supports coordinator scheduling individual #2's ISP without a 30 day notice. The program specialist was trained on 1/30/18 as to the regulation 181.f stating that the individual and team members were informed of the results of the assessment at least 30 calendar days prior to the ISP meeting.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.183(3) | Individual #1's Individual Support Plan (ISP) socialization outcome and Individual #2's independence/socialization outcome did not include a method of evaluation used to determine progress towards the outcomes. Their ISPs indicated that the supports coordinator was going to determine progress by performing monitorings. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | The ISP must include the following: current status in relation to the outcome and a method of evaluation used to determine progress toward the expected outcome. The method of evaluation used to determine progress towards outcomes for individual #1 was updated on the outcome sheet (2/2/18) by the program specialist and the updated documentation was sent to the supports coordinator in order to update the ISP.
The outcome sheet for individual #2 was updated to include the method of evaluation used to determine progress towards his outcome (2/2/18). The updated outcome will be used to update the ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.183(4) | Individual #1's Individual Support Plan (ISP) did not include his/her supervision needs at day program and in the community. His/Her ISP only indicated the need for a 1:3 staffing ratio at day program. According to his/her record information he/she is an elopement risks and has seizures so he/she needs closely monitored/supervised due to those risks and also needs to hold staff's hand in the community so he/she will not elope. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | The ISP must including the following: a protocol and schedule outlining specified periods of time for the individual to be without direct supervision. The protocol must include a current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. The program specialist will communicate with the supports coordinator for individual #1 on (1/31/18) on the current level of independence and the need for staffing ratio at the day program and in the community while with the day program. The program specialist will communicate the discrepancy on (2/6/18) relative to the staffing ratio while at the day program and the staffing ratio while in the community while with the day program. The program specialist contacted the supports coordinator to schedule a team meeting to discuss discrepancy's, concerns, and updates needed in individual #1's plan (2/1/18).
The assessment must include the following:; the individual's need for supervision. The assessment was updated by the program specialist on (2/2/18) to including the following: the individual's need for supervision. The program specialist will update individual #1's assessment to indicate her supervision needs at the day program and while in the community with her day program. The program specialist will forward the updated assessment (2/6/18) to individual #1's supports coordinator for updates needed to individual l#1's ISP.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.186(a) | Individual #2's Individual Support Plan (ISP) reviews not review the dates of 5/25/17 and 5/26/17. His/Her ISP that covered the period from 2/29/17-5/29/17 was completed on 5/24/17, prior to the end of the review period. The next ISP review covered the period from 5/29/17-8/29/17 and did not include a review of the missing two days. | 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 individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | The program specialist shall complete an ISP review of services and expected outcomes specific to the facility licensed under this chapter with the individual every 3 months or more frequently. The program specialist updated (2/2/18) Individual #2's ISP review updated to include review period 2/29/17-5/29/17, including dates 5/25/17 and 5/26/17. The program specialist was retrained on the timeframe of ISP reviews on 1/26/18.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews did not include a review of his/her participation and progress towards his/her socialization outcome. The ISP reviews indicated, in quotes, he/she met the objective for the most part and will move to the next step, end quote. Individual #1 was absent for approximately half of every quarter and did not meet his/her outcome steps. Individual #2's ISP reviews did not include a review of his/her participation and progress towards his/her independence/socialization outcome. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | The ISP review must included the following: a review of monthly documentation of participation and progress during the prior 3 months towards the outcome. The ISP review was updated (2/2/18) to include the following: participation towards the outcome. The program specialist updated (2/2/18) Individual #1's ISP review updated to include review of her participation and progress towards her socialization outcome.
The program specialist updated (2/2/18) Individual #2's ISP review updated to review his participation and progress towards his independence/socialization outcome.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews did not include a review of his/her participation and progress towards his/her socialization outcome. The ISP reviews indicated, in quotes, he/she met the objective for the most part and will move to the next step, end quote. Individual #1 was absent for approximately half of every quarter and did not meet his/her outcome steps. Individual #2's ISP reviews did not include a review of his/her participation and progress towards his/her independence/socialization outcome. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The ISP reviews for individual #1 was updated to include each session of the ISP specific to the facility licensed under this chapter, including individual #1 participation and progress towards her socialization outcome. The update (2/2/18) took into account individual #1 absences and lack of progress on her outcome steps towards achievement on her outcome.
The ISP reviews for individual #2 were updated to include participation and progress towards each section of the ISP specific to the facility licensed under this chapter and to include his participation and progress towards his independence/socialization outcome.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.186(e) | Individual #1's mother and new supports coordinator were not offered the option to decline Individual #1's Individual Support Plan (ISP) reviews. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The program specialist was retrained on the option to decline on 1/26/18. The program specialist did not offer the option to decline the ISP review documentation to individual #1 parent by providing an option to decline sheet. Individual #1's Supports Coordinator is the plane lead; therefore, cannot decline the option to not receive ISP review documentation. The program specialist provided copies of ISP reviews to the supports coordinator; the program specialist provided copies of ISP reviews to the parent (2/2/18). The program specialist will present the option to decline to the parent and completed the option to decline form as individual #1's upcoming ISP meeting.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |
| 2380.188(b) | Individual #1 was not offered the opportunity to participate in community life. The provider indicated Individual #1 does not go into the community with the day program on any outings and there was no documentation to support why this was not offered to Individual #1. Individual #2 was not offered the opportunity to participate in community life due to his need for a handicapped accessible van and the agency not having one. | The facility shall provide opportunities and support to the individual for participation in community life, including work opportunities. | The facility shall provide individual #1 and individual #2 opportunities for participation in community life, including volunteering. The facility offers opportunities for participation in community life, including volunteering at the facility's monthly client meeting. The program specialist updated individual #1 and individual #2's (on 2/2/18) ISP reviews to document the opportunities offered in the individual's reports (monthly, quarterly, and annual). The program specialist will collect data for individual #2 and report (monthly, quarterly, and annual) interactions with community members in the immediate locale of the facility, to include but not limited to outside therapists.
Staff training as well as quarterly file reviews will occur. All program specialists will be retrained on the requirements of charts and associated reports within 30 days of receipt of this plan. The Facility Director will oversee and monitor this process of correction (2017-18). |
02/02/2018
| Implemented |