| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.104(4) | Individual #10's record did not include medical information that is pertinent to treat/diagnose in the event of an emergency. | Emergency medical information for a client shall be readily accessible. Emergency medical information for a client shall include the following: Medical information pertinent to diagnosis and treatment in case of emergency. | Program Specialist will utilize revised emergency medical form and update individual #10's records to comply with 2390.104(4) by 8/17/23. Program specialists will review cases to ensure 2390.104(4) is addressed in each record by 9/1/23.
attachment:
Revised emergency medical #10 Ebg |
09/01/2023
| Implemented |
| 2390.151(e)(1) | Individual # 1's most recent assessment completed on 9/26/22 failed to address individual's functional strengths. Individual # 6's most recent assessment completed on 1/6/23 does not identify their functional strengths or needs. Individual #11's most current assessment completed on 12/23/22, did not identify their needs. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | Program Specialist will amend individual #1's assessment to identify their functional strengths by 8/17/23 and distribute to ISP team members. Program Specialist will amend individual #6's assessment to identify their functional strengths and needs by 8/17/23 and distribute to ISP team members.Program Specialist will amend individual #11's assessment to identify their needs by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)1 is addressed in its entirety by 9/1/23.
Attachment:
Revised assessment #1 Ebg
Revised assessment #6 Ebg
Revised assessment #11 Ebg
Ebensburg Training Sheet |
09/01/2023
| Implemented |
| 2390.151(e)(2) | Individual #8's current assessment completed on 7/27/23 does not identify their dislikes. | The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client. | Program Specialist will amend individual #8's assessment to identify their dislikes by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)2 is addressed in its entirety by 9/1/23.
attachment:
Revised assessment #8 Ebg
Ebensburg training sheet |
09/01/2023
| Implemented |
| 2390.151(e)(4) | Individual #2's assessment, dated 5/12/23, does not address specific supervision needs. The ISP states they need line of sight supervision, and the assessment does not indicate this, it only indicates moderate supervision is needed. | The assessment must include the following information: The client's need for supervision. | Program Specialist will amend individual #2's assessment to identify their need for supervision by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)4 is addressed accurately with the ISP by 9/1/23.
Attachment:
Ebensburg Training sheet
Revised assessment #2 Ebg |
09/01/2023
| Implemented |
| 2390.151(e)(8) | Individual #4's most recent assessment, dated 1/27/23, does not address the individual's ability to evacuate the building. This section simply states that fire drills are conducted quarterly with an annual safety training. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | Program Specialist will amend individual #4's assessment to identify their ability to evacuate the building by 8/17/23 and distribute to ISP team members. Program Specialists will review cases to ensure 2390.151(e)8 is addressed in its entirety by 9/1/23.
Attachment:
Ebensburg training sheet
Revised assessment #4 Ebg |
09/01/2023
| Implemented |
| 2390.151(b) | Individual #3's current assessment is dated 1/13/23. At the time of the assessment, individual #3 was on an extended LOA from the program. Individual #3 then returned from their LOA on 2/27/23 however no update was made to the assessment to address any changes upon the individual's return such as changes in health, days attending, outcomes, recommendations, etc. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the client shall have an assessment completed as required under the section. | Program Specialist will complete an updated assessment by 8/17/23 and send to ISP team. Program Specialists will review other assessments in which an individual was on a LOA and update if necessary by 9/1/23.
Attachment:
Ebensburg training sheet
Revised assessment #3 Ebg |
09/01/2023
| Implemented |