| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Direct Service Worker #1, date of hire 2/28/2024, was instructed in general fire safety and the use of fire extinguishers 3/01/2024. Direct Service Worker #2, date of hire 9/25/2023, was instructed in general fire safety and the use of fire extinguishers 9/29/2023. | 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. | The staff orientation and the department orientation forms were reviewed and revised on 4/11/2024 by the Director of Compliance to include staff instruction immediately upon day of hire in general fire safety and in the use of fire extinguishers |
04/11/2024
| Implemented |
| 2390.151(e)(6) | Individual #4's assessment completed 1/05/2024 does not assess the individual's ability to use poisonous materials. | The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to better guide staff writing assessments in appropriately documenting an individual¿s use of poisonous materials.
The Program Specialists were trained by the Director of Compliance and the Quality Improvement Specialist on 4/10/2024 concerning proper documentation of an individual¿s ability to use poisonous materials.
The corresponding Program Specialists will review and revise as necessary all assessments under their responsibility to appropriately document an individual¿s ability to use poisonous materials. |
04/11/2024
| Implemented |
| 2390.151(e)(8) | Individual #1's assessment completed 3/17/2024, Individual #2's assessment completed 2/16/2024, and Individual #3's assessment completed 3/14/2024 does not assess their ability to evacuate in the event of a fire. The assessments only document that they attend annual fire safety training and participate in evacuation drills. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to better guide staff writing assessments in appropriately documenting an individual¿s ability to evacuate in the event of a fire.
Staff were trained by the Director of Compliance and the Quality Improvement Specialist on 4/10/2024 concerning proper documentation of an individual¿s an individual¿s ability to evacuate in the event of a fire.
The corresponding Program Specialists will review and revise as necessary all assessments under their responsibility in order to appropriately document an individual¿s ability to evacuate in the event of a fire. |
04/11/2024
| Implemented |
| 2390.151(f) | Individual #4's assessment completed 1/05/2024, was provided to the plan team members 1/05/2024, for the individual meeting which occurred 1/30/2024. Individual #5's assessment completed 3/17/2023, was provided to the plan team members 3/17/2023, for the individual meeting which occurred 4/13/2023. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | The assessment form was reviewed and revised on 4/10/2024 by the Quality Improvement Specialist to clearly document the assessment completion date verses the assessment due date.
The Program Specialists will gather all participants Annual ISP dates as well as Annual Assessment dates. From this information, Program Specialists will create an updated schedule so that CPS Assessments are completed more than 30 days prior to the next ISP. In best practice these will be scheduled approximately 6 months from the anticipated date of the next ISP. |
04/30/2024
| Implemented |