| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(7) | The program specialist did not report content discrepancies withiin Individual #1's record to his/her supports coordinator. Another office staff was reporting content discrepancies within Individual #1's record to his/her supports coordinator. | The program specialist shall be responsible for the following: Reporting content discrepancy to the SC or plan lead, as applicable, and plan team members. | 2380.33(b)(7)
The program specialist is aware that is her responsibility to report discrepancies, this was reviewed with her by the CEO/President. Although all team members need to review the plan as well and share any information/discrepancies that they have found, it will be the sole responsibility of the Program Specialist to update the Supports Coordinator to have these areas addressed as quickly as possible. The Program Specialist will print out any corresponding emails that address this issue with an SC. (Attachment # 3) |
04/07/2017
| Implemented |
| 2380.58(a) | The wall soap dispenser in the women's and men's bathroom was broken and held together by duct tape. | Floors, walls, ceilings and other surfaces shall be in good repair. | 2380.58(a)
Floors, walls, ceilings and other surfaces shall be in good repair. The soap dispensers that where in poor repair have been replaced (picture 2) The ATF leader will complete a weekly report that will help maintain all physical site regulations (Attachment 7) |
04/07/2017
| Implemented |
| 2380.82 | An approximately 8 foot long table plus chairs were positioned in front of the door between the computer room and main program room in such a way that prevented the door from being opened. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | 2380.82
Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. The table and chairs that were positioned in front of the door between the computer room and main program room has been removed. (Picture #1) The ATF leader will complete a weekly report that will help maintain all physical site regulations (Attachment 7) |
04/07/2017
| Implemented |
| 2380.128(e) | Staff #1 was certified to be a practicum observer on 10/7/16. Documentation of all his/her observations completed, 8/19/16, 9/11/16, 9/13/16, 9/26/16, and 10/7/16, was not kept. Staff #2 was certified to be a practicum observer on 9/7/15. Documentation of 2 of his/her medication administration record reviews were not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 2380.128(e)
Staff # 1 documentation was found an is attached (attachment 5) Record keeping is the responsibility of the trainer and this has been reviewed with her by the President/CEO (attachment 6) Staff 2 records where not located and he is no longer an employee of the company and has been gone for several months. |
04/07/2017
| Implemented |
| 2380.176(a) | Program information for Individuals #2 and #3 pertaining to their current Individual Support Plan (ISP) outcomes they are working was left unlocked when unattended in the computer room. | Individual records shall be kept locked when they are unattended. | 2380.176(a)
The President/CEO has met with the ATF team and reviewed this regulation. Each personal book and/or information shall be kept locked at all times unless it is being used at that time. (Attachment 4) |
04/07/2017
| Implemented |
| 2380.181(e)(1) | Individual #1's 6/1/16 assessment did not include his/her functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 2380.181(e)(1)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the functions strengths, needs and preferences of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(3)(i) | Individual #1's 6/1/16 assessment did not include his/her current level of performance and progress in acquisition of functional skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Acquisition of functional skills. | 2380.181(e)(3)(i)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the acquisition of functional skills and the progress and growth of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(3)(iii) | Individual #1's 6/1/16 assessment did not include his/her current level and performance and progress in personal adjustment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | 2380.181(e)(3)(iii)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the progress and growth in the area of personal adjustment of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(4) | Individual #1's 6/1/16 assessment did not include his/her need for supervision. | The assessment must include the following information: The individual¿s need for supervision. | 2380.181(e)(4)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the level of supervision required during the ATF hours for the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(7) | REPEAT from 3/30/16 annual inspection: Individual #1's 6/1/16 assessment did not include his/her knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees fahrenheit. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | 2380.181(e)(7)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 F and are not insulated. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(13)(ii) | REPEAT from 3/30/16 annual inspection: Individual #1's 6/1/16 assessment did not include his/her progress in motor and communication skills. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | 2380.181(e)(13)(ii)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the progress and growth in the area of motor and communication skills of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's 6/1/16 assessment did not include his/her progress in personal adjustment. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | 2380.181(e)(13)(iii)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the progress and growth in the area of personal adjustment of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 6/1/16 assessment did not include his/herr progress in socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | 2380.181(e)(13)(iv)
Individual 1 Assessment (attachment #3) has been updated and sent to parties it includes the progress and growth in the area of socialization skills of the individual. The program specialist and the compliance officer have been re-trained by the CEO on the 2380 regulations (attachment #2), especially in the areas of assessment. Assessments will be reviewed for accuracy by the compliance officer and program specialist. |
04/07/2017
| Implemented |
| 2380.183(4) | According to staff at the time of licensing on 3/7/17, Individual #1 required arms length supervision from his/her 1:1 staff at all times when at the day program and in the community with the day program staff. Individual #1's Individual Support Plan (ISP) did not indicate that he/she requires arms length supervision. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | 2380.183 (4)
The ISP has been reviewed and his assessment has been updated (attachment #3) and sent to his Supports Coordinator so that she may include the level of supervision in all areas while attending the ATF. Individual 1 level of supervision was not correct and that information was sent to her via email by the program specialist. The program specialist will review all plans for accuracy in all settings for the level of supervision that is required. |
04/07/2017
| Implemented |
| 2380.186(c)(2) | REPEAT from 3/30/16 annual inspection: Individual #1's Individual Support Plan (ISP) reviews did not review his/her 1:1 supervision level. ISP reviews completed on 12/30/16, 9/29/16, and 3/17/16 did not review Individual #1's behavior support plan. The reviews indicated to "see behavior support quarterly" however the program specialist indicated that the behavior support quarterlies are not sent with the ISP reviews. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | 2380.186(c)(2)
The ISP reviews completed on 12/30/16, 09/29/16 and 03/17/17 did review Individual #1¿s behavior support plan. In the email it was also sent at that time. Emails are attached (#1) verifying that they were. Although they were not printed off and placed in the program book with the review of the outcomes. SHS will continue to send all of the documentation together, but will now print off all reports and place them in the program book. |
04/07/2017
| Implemented |