| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Staff #2's date of hire was 7/15/14 but didn't have fire safety training until 7/21/14. Staff #3's date of hire was 8/26/14 but didn't receive fire safety training until 8/29/14. Staff #4 had fire safety training on 2/7/14 but not again until 2/9/15. | 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. | HR staff, are responsible for ensuring that staff shall be instructed upon initial employment, and staff are responsible to ensure that they are re-instructed annually in general fire safety and in the use of fire extinguishers. The orientation schedule has been changed to adopt this practice (see attachment #16). Staff #4 was retrained on this requirement (see attachment #17). |
09/04/2015
| Implemented |
| 2390.111(a) | There was no preadmission interview conducted for Individual #3. | A client shall have a preadmission interview. | Program Specialists are responsible for ensuring that a preadmission interview is conducted with clients who have applied for admission into programs. Program Specialists have been retrained on this information (see attachment #5). A Preadmission Interview Form used for an individual who has recently started is enclosed (see attachment #15) |
09/04/2015
| Implemented |
| 2390.112(b) | Upon admission, Individual #4 did not receive written information about work hours, benefits, and leave policy. | 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 (see attachment #5). An orientation checklist is attached (see attachment #14) for a new individual. |
09/04/2015
| Implemented |
| 2390.151(a) | Individual #3's date of entry was 11/10/14 and their initial assessment was not completed until 2/17/15. | 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. Program Specialists have been retrained in this information (see attachment #5). The Shadowfax facility at Tremont Street did not have any new individuals start between the period of 6/25/15 and 9/1/15. An individual started on 9/3/15. A copy of that assessment will be sent to licensing on 10/30/15.
A total record review will be conducted. Any client¿s ISP not documented on the designated form will be placed on the correct form.
|
11/30/2015
| Implemented |
| 2390.151(f) | The assessment for Individual #4 was not sent at least 30 calendar days before his annual Individual Support Plan (ISP) meeting. Individual #4's assessment was sent on 10/22/14 and his ISP meeting was held on 11/16/14. | 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 for ensuring that the assessment is provided to the SC or Plan Lead at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP. Program Specialists have been retrained on this information (attachment #5). Enclosed is an ISP Annual Meeting signature sheet (see attachment #11), the assessment cover letter (see attachment # 12), and the first page of the assessment (see attachment #13), for an individual who¿s time frames for this regulation fell after licensing on June 25, 2015 and within the regulatory timeframes.
A total record review will be conducted. Assessment addendums for areas that need to be corrected will be completed and distributed to team members.
|
11/30/2015
| Implemented |
| 2390.152(d)(3) | The Individual Support Plan (ISP) for Individual #3 was not on designated form located in the Home and Community Services Information System. | The plan lead shall develop, update and revise the ISP according to the following: The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) And also on the Department's web site. | Program Specialists are responsible for developing, updating, and revising the ISP according to the following: The ISP, annual updates and revisions shall be documented on the Department designated form located in the Home and Community Services Information System (HCSIS) and also on the Department website. The Program Specialists have been retrained in this information (see attachments #5 and #9).
A total record review will be conducted. Any client¿s ISP not documented on the designated form will be placed on the correct form.
|
11/30/2015
| Implemented |
| 2390.152(d)(4) | The Individual Support Plan (ISP) invitation letter for Individual #3 was sent to team members on 1/15/15 and his ISP meeting was held on 1/21/15. | The plan lead shall develop, update and revise the ISP according to the following: An invitation shall be sent to plan team members at least 30 calendar days prior to an ISP meeting. | Program Specialists are responsible to ensure that an ISP invitation letter is sent at least 30 days prior to an ISP meeting. Program Specialists have been retrained on this requirement (see attachment #5). An invitation letter, which was sent recently, complies with this requirement (see attachment #10).
A total record review will be completed. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
11/30/2015
| Implemented |
| 2390.153(1) | There was no outcome in the Individual Support Plan (ISP) for Individual #2 that Shadowfax vocational facility was responsible for documenting. | 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. | The Program Specialist for client #2 has for contacted the Supports Coordinator to include in the ISP, the Service provided to the client and expected outcomes chosen by the client and the client¿s plan team. The Team met on June 29 to discuss the changes needed for Client #2 (See attachments #1, & 2) resulting in those changes being made (see attachments #3 & 4). Program Specialists are responsible for ensuring that all ISPs reflect the expected outcomes and who is responsible for documenting. Program Specialists have been retrained in this information (see attachment #5).
A total record review will be conducted. ISP¿s which are not in compliance will be corrected.
|
11/30/2015
| Implemented |
| 2390.153(5) | Individual #4 was diagnosed with anxiety and prescribed Alprazolam. There wasn't a protocol to address the social, emotional, and environmental needs of Individual #4. | 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. | The Program Specialist responsible for client #4 will ensure that a support plan is in place in the ISP and signed and dated by both the client and the Program Specialist (see attachment #6 &7). 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 #5). |
11/30/2015
| Implemented |
| 2390.153(7)(i) | The Individual Support Plan (ISP) for Indvidual #4 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 #5). ). Enclosed is correspondence to Individual #4¿s Supports Coordinator to add this information to their ISP¿s. (see attachment #8).
A total record review will be conducted. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
11/30/2015
| Implemented |
| 2390.153(7)(ii) | The Individual Support Plan (ISP) for Indvidual #4 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 #5). Enclosed is correspondence to Individual #4 Supports Coordinators to add this information to their ISP¿s. (see attachment #8). This individual has not been in the program long and the team decided to wait a little to put supported employment as a vocational option.
A total record review will be completed. Correspondence will be sent to Supports Coordinators requesting correct information be included in the ISP.
|
11/30/2015
| Implemented |