| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.85(a)-2 | The 2/1/24 fire drill does not include the amount of time it took to evacuate the facility. The time of day is written in the evacuation time box on the form. | A written record shall be kept of the date, hypothetical location of fire and the amount of time it took for evacuation. | Current fire drill logs have designated areas to fill out including date, hypothetical location of fire and the amount of time it took for evacuation. There was an error in written record where staff member put the time of the drill rather than the time it to evacuate.
To maintain correction, there will be two required signatures on the log to ensure the logs are being completed and filled out appropriately. The staff member completing the fire drill and the PS or PM will review and sign as well. The updated log is attached. |
03/28/2024
| Implemented |
| 2390.87 | There is no record of individuals#1, #2receiving fire safety training upon admission. | 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. | Program Specialist conducted a fire safety training and use of extinguisher training for clients on March 25th, 2024 and March 26th, 2024. Two dates were utilized due to an absence of client. Please find the training log and certificates for both individuals attached and labeled as attachment 3. |
03/28/2024
| Implemented |
| 2390.151(a) | The assessment for individual#1 was completed on the date of admission, 9/7/23, rather than within 60 days of the individual's admission and is missing components of the assessment including a lifetime medical history, Personal needs with or without assistance from others, personal adjustment and current level of vocational skills within initial assessment period. The annual assessment was then completed 6 months later, on 3/11/24 and does not include a lifetime medical history, information regarding personal needs with or without assistance from others, nor progress regarding health or socialization.
The assessment for individual#2 was completed on the individual's date of admission, 9/18/23, rather than within 60 days of admission and is missing components of the assessment including a lifetime medical history, Personal needs with or without assistance from others, personal adjustment and current level of vocational skills within the initial assessment period. The annual assessment was then completed 5 months later, on 2/1/24 and does not include a lifetime medical history, information regarding personal needs with or without assistance from others, nor progress regarding health or socialization. | 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 Specialist has updated the assessment to include lifetime medical history, personal needs with or without assistance from others, personal adjustment and current level of vocational skills on March 26, 2024. Program Specialist added an additional reviewer and signature space on the form to ensure accuracy and completion on a regular basis on March 26h, 2024. |
03/28/2024
| Implemented |
| 2390.21(u) | The client rights for individual#1 were not reviewed upon admission on 9/7/23. They were first reviewed on 3/11/24.
The client rights for individual#2 were not reviewed upon admission on 9/18/23. They were first reviewed on 3/12/24. | The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter. | Program Specialist will review and explain client rights and the process to report a rights violation annually to both the client and caregiver. This has recently been conducted on 3/11 and 3/12 by Program Specialist. Program Specialist will ensure all clients are current on the client rights and acknowledgement. |
03/28/2024
| Implemented |
| 2390.151(f) | There is no documentation on record indicating that the program specialist provided a copy of the assessment to the team 30 days prior to the ISP meeting for individual#1, which occurred on 2/13/23.
There is no documentation on record for individual#2 indicating that the program specialist provided a copy of the assessment to the team 30 days prior to the ISP meeting. ISP meeting is scheduled for 3/18/24. | 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 sent out a copy on 3/28/2024 of most recent assessment to members of each participants ISP team. Please see attachment #4 for the new check box included in assessment, located on the last page of the assessment. |
03/28/2024
| Implemented |