| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Staff #1 and #4 had fire safety training on 2/14/13. They were not trained again in fire safety until 2/26/14. | 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. | This training was held late due to inclement weather. As a result, EARS is scheduling the Fire Safety training for Jan. 2015 and again in June 2015. The training will be held annually in June from then on to prevent this from occurring again. Client Services Director will be responsible for scheduling this training. |
11/04/2014
| Implemented |
| 2390.151(e)(5) | The assessment for individuals #1, #2, #4, #5, #6, #7, and #8 did not include their ability to self administer medications. | The assessment must include the following information: The client's ability to self-administer medications. | Included is a copy of another Individual's ability to self-medicate (attachment A4). This assessment was completed immediately after licensing and includes the Individual's ability to self-medicate. All Program Specialists at Fulton St. were trained on assessing an Individual's ability to self-medicate, even when they do not take medication at EARS. The Program Specialist will be responsible for ensuring this information is included in the assessment. All records were reviewed for compliance. All assessments were amended to reflect self-administration ability. |
10/03/2014
| Implemented |
| 2390.151(e)(13)(i) | The assessment for individual #1 did not contain progress and growth in the area of Health. | 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. | Included is a copy of this Individual's updated assessment (attachment A3). The assessment was updated to include progress and growth in the area of Health. All Program Specialists at Fulton St. were trained on their responsibility to assess progress and growth in all sections of the assessment. The Program Specialist will be responsible for ensuring this information is reviewed in the assessment. All records were reviewed for compliance. |
10/03/2014
| Implemented |
| 2390.153(7)(ii) | The Individual Support Plan for individual #7 did not include their potential to advance in competitive 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. | Included is an Annotated ISP revision for this Individual, which includes her potential to advance to competitive employment (attachment A2). All Program Specialists at Fulton St. were trained on their responsibility to include in the ISP an Individual's potential to advance to competitive employment. The Program Specialist will be responsible for ensuring this information is included in the ISP. All ISP's were reviewed for compliance. |
10/02/2014
| Implemented |
| 2390.156(c)(2) | The Individual Support Plan reviews for Individual #8 dated 8/20/14, 5/20/14, 2/20/14, and 11/20/13 did not review his 1:1 supervision plan or Social Emotional Environmental Plan. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Included is an ISP review which was completed 11/20/14 (attachment A1). This Individual has a SEEP and this information was reviewed in the ISP review. All Program Specialists at Fulton St. were trained on the proper review of SEEP information at the ISP review, to prevent this from occurring again. The Program Specialist will be responsible for ensuring this information is reviewed. |
10/24/2014
| Implemented |