| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The finish is coming off of 3 of the kitchen cabinets. | Floors, walls, ceilings and other surfaces shall be in good repair. | An agency request was completed by Program Specialist to have the finish on the cabinets repaired by maintenance. This was request was completed and dated for 10/6/17. See Attachment #7. A Painter has been contracted to complete the work with the completion date noted as 11/20/17 |
11/20/2017
| Implemented |
| 6400.104 | Individual #1 required physical prompts to evacuate during a fire drill due to his/her hearing impairment. The home only notified the local fire department that Individual #1 required verbal prompts to evacuate the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter to the fire chief was sent on 8/21/17 by Program Specialist. This letter includes individual #1 requiring physical prompts, such as the bed shaker and strobes, to evacuate the home in the event of a fire or fire drill. The other individuals that reside in the home (not included in the sample) were assessed to see if their evacuation requirements needed updated. They did not. This assessment was completed by Program Specialist on 8/21/17. See attachment #6 |
08/21/2017
| Implemented |
| 6400.142(f) | Individual #1 requires assistance with his/her dental care and mouthwash and he/she did not have a dental hygiene plan in place. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | An addendum was added to individual #1s skill assessment that included individuals dental plan. This addendum was added on 9/18/17 by program specialist. Other individuals (not included in the sample) skill assessments were reviewed to assess whether their skill assessment/ISP included a dental plan. They did. This review was completed on 9/18/17 by program supervisor. See Attachment #4b |
09/18/2017
| Implemented |
| 6400.181(e)(4) | Individual #1's 6/22/17 assessment did not include his/her need for supervision during the overnight sleeping hours. | The assessment must include the following information: The individual's need for supervision.
| Individual¿s assessment was revised on 9/18/17 by program specialist, to include her need for supervision for overnight sleeping hours. The other individuals¿ (not included in the sample) skill assessments were reviewed for this missing information on supervision overnight, by program supervisor, on 9/18/17. The other two assessments were missing information on supervision overnight, as well. An addendum was added to the other two skill assessments on 9/18/17, by program specialist. See Attachment #4a |
09/18/2017
| Implemented |
| 6400.181(e)(10) | Individual #1's 6/22/17 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | )- Individual¿s lifetime medical history was completed but not filed with skill assessment. Individual¿s lifetime medical history was stapled to the skill assessment on 9/14/17 by program supervisor. Program specialist signed off on this attachment. An item was added to the skill assessment outline to include a section to sign off on to indicate the lifetime medical history was stapled to the skill assessment by program specialist. See Attachment #5b |
09/14/2017
| Implemented |
| 6400.181(e)(12) | Individual #1's 6/22/17 assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An addendum was added to individual #1¿s skill assessment that included recommendations for specific areas of training , programming, and services. This addendum was added on 9/18/17 by program specialist. Other individuals¿ (not included in the sample) skill assessments were reviewed to assess whether they had recommendations for specific areas of training, programming, and services. Recommendations were included. This review was completed on 9/18/17 by program supervisor. See Attachment #4a |
09/18/2017
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's 6/22/17 assessment did not include his/her progress in health. This section was completely missing from the assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| An addendum was added to individual #1¿s skill assessment that included progress in health. This addendum was added on 9/18/17 by program specialist. Other individuals¿ (not included in the sample) skill assessments were reviewed to assess whether they had showed progress in the health section. They did. This review was completed on 9/18/17 by program supervisor. See Attachment #4a |
09/18/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 6/22/17 assessment did not include his/her progress in activities of residential living. The assessment was verbatim to the 6/22/16 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | An addendum was added to individual #1's skill assessment that included progress in activities of residential living. This addendum was added on 9/18/17 by program specialist. Other individuals¿ (not included in the sample) skill assessments were reviewed to assess whether they showed progress in the areas of activities of residential living. They did. This review was completed on 9/18/17 by program supervisor. See Attachments #4a & 4b |
09/18/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's 6/22/17 assessment did not include his/her progress 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. | An addendum was added to individual #1¿s skill assessment that included progress in community integration. This addendum was added on 9/18/17 by program specialist. Other individuals¿ (not included in the sample) skill assessments were reviewed to assess whether they showed progress in the areas of community integration. They did. This review was completed on 9/18/17 by program supervisor. See Attachment #4b |
09/18/2017
| Implemented |
| 6400.181(f) | Individual #1's 6/22/17 assessment was sent to team members on 6/22/17 however his/her Individual Support Plan (ISP) meeting was held 7/12/17. | (f) The program specialist shall provide the assessment to the SC, 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).
| Another individual¿s (not included in this sample) ISP meeting was scheduled for 10/31/17 The skill assessment was sent on 9/29/17, which is 30 days prior to the meeting. This assessment was sent by program specialist. Program supervisor signed off that skill assessment was sent 30 days prior to the ISP meeting. A skills assessment/ISP schedule was completed by program supervisor. This will be used as a worksheet to ensure items are sent to SC, on time. See Attachment #5a |
09/29/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews completed on 6/28/17, 3/28/17, 12/28/16, and 9/26/16 did not include a review of his/her behavior support plan. The ISP reviews indicated that "he/she is not on any medication to address maladaptive behaviors and there is no plan of support or behavior support plan." However Individual #1 is on medications to treat depression and has a behavior support plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Addendums were included with individual¿s ISP reviews dated 6/28/17, 3/28/17, 12/28/16, 9/26/16 that included updated information/progress on individual¿s BSP and psychotropic medications, and maladaptive behaviors. These addendums were completed by program supervisor and were reviewed by program director. Individual¿s most current ISP review dated 9/26/17, includes a review of individual¿s BSP and maladaptive behaviors and psychotropic medication information, completed by program supervisor and reviewed by program director. Program director reviewed other individuals¿ (not included in the sample) ISP reviews for missing information regarding maladaptive behaviors, BSPS, or psychotropic medications. Nothing needed Included. See Attachment #2 |
09/26/2017
| Implemented |
| 6400.186(e) | There was no documentation in Individual #1's record that the program speciliast notified Individual #1's team members of the option to decline the Individual Support Plan (ISP) review documents. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | A declination form was completed by program specialist on 9/18/17. Program supervisor reviewed that the declination form was completed and signed on 10/11/17. Other individuals¿ (not included in the sample) files were reviewed for the presence of declinations forms on 9/18/17. They were included in their files. See Attachment #3 |
10/11/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include documentation of identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual¿s face sheet was updated on 10/3/17, by program specialist, to include identifying marks. Other individual¿s face sheets were reviewed on 10/3/17, by program specialist, for any information missing on other individual¿s face sheets. There was no missing information. Program specialist signed off on all individual face sheets, residing in the home, to indicate they were reviewed and complete. An outline was created by program specialist on 10/11/17. This outline will include identifying marks and will be utilized for all future face sheets. See Attachment #1 |
10/11/2017
| Implemented |