| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(6) | Individual #1's bedroom was not equiped with a mirror. | In bedrooms, each individual shall have the following: A mirror. | Each bedroom shall have a secured mirror on the wall that cannot be removed without being screwed out by maintenance, unless of course it is written in that particular individual¿s ISP and/or BSP. The mirror for this gentlemen has been located and has been attached to his wall. See Picture #1. Part of the house leader¿s responsibility will be to ensure and sign off that all individuals have everything in their bedroom per 6400 regulations. See attached verification sheet that all house leaders are aware and the form that will be completed (attachment #8). Licensing Compliance will also ensure that all physical sites are within compliance as well. |
01/20/2017
| Implemented |
| 6400.142(f) | Individual #1's record did not include a written plan for dental hygiene. Individual #'1 required verbal prompting to complete daily hygiene of brushing and flossing his/her teeth twice a day. | 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. | Attached # 9 is the updated Dental Plan of Care for individual #1. All dental plan of cares will outline the level of supervision required, what level of verbal prompting, gestural prompting and physical prompting that each individual requires, with brushing, flossing and rinsing. If an individual has achieved dental hygiene independence that also would be reflected in there ISP and assessment. |
01/20/2017
| Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan (ISP) does not include a protocol to address his/her social, emotional, and environmental needs. Individual #1 was prescribed Escitalopram for Depression and Lorazepam for Anxiety. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Supports Coordinator was contacted to set up a date to review the ISP as a team and to ensure all areas outlined in the 6400 regulations are documented on and reviewed by the Program Specialist for any discrepancies. (Attachment # 9)Individual¿s SEEP was updated and sent to the Supports Coordinator and team members (Attachment #10). The Program Specialist as well as Licensing Compliance will review individual¿s ISP to ensure accuracy. If any errors are found the Program Specialist will reach out to the Supports Coordinator and documentation will be kept. |
01/20/2017
| Implemented |
| 6400.183(7)(ii) | Individual #1's Individual Support Plan (ISP) does not include his/her potential to advance in community involvement. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Community involvement. | An assessment outline has been created to ensure that all areas of the assessment are reviewed and any progress and growth is documented when necessary. In areas where potential advancement maybe made, documentation in the assessment will include progress or lack of progress in these areas. The Program Specialist will create and write all assessments and ensure all documentation is forwarded to the appropriate parties. Licensing Compliance will review all documentation to ensure compliance with the 6400 regulations. With ensuring all of the documentation from the assessment is completed and given to the Supports Coordinator within the allotted time, all areas of the ISP can be updated with the most current information. Once again, ISP reviews will be completed and if any discrepancies and/or missing information is found, the Program Specialist will ensure notification is made to the SC and documentation showing that this has been done will be placed in the individual¿s book (Attachment #7) |
01/20/2017
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) does not include his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | An assessment outline has been created to ensure that all areas of the assessment are reviewed and any progress and growth is documented when necessary. In areas where potential advancement maybe made, documentation in the assessment will include progress or lack of progress in these areas. The Program Specialist will create and write all assessments and ensure all documentation is forwarded to the appropriate parties. Licensing Compliance will review all documentation to ensure compliance with the 6400 regulations. With ensuring all of the documentation from the assessment is completed and given to the Supports Coordinator within the allotted time, all areas of the ISP can be updated with the most current information. Once again, ISP reviews will be completed and if any discrepancies and/or missing information is found, the Program Specialist will ensure notification is made to the SC and documentation showing that this has been done will be placed in the individual¿s book (Attachment #7) |
01/20/2017
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) does not include his/her potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| Supports Coordinator was contacted to set up a date to review the ISP as a team and to ensure all areas outlined in the 6400 regulations are documented on and reviewed by the Program Specialist for any discrepancies. (Attachment # 9)Assessment has been updated to include any recommendations from the Program Specialist and will be reviewed at this meeting with the individual and his team members. The Program Specialist as well as Licensing Compliance will review individual¿s ISP to ensure accuracy. If any errors are found the Program Specialist will reach out to the Supports Coordinator and documentation will be kept. |
01/20/2017
| Implemented |
| 6400.213(11) | Repeat violation from 9/14/15 renewal inspection: Individual #1's Individual Support Plan (ISP) does not include his/her allergy to Ibuprophen. Individual #1's medication logs indicated that he/she was allergic to Ibuprophen. Individual #1's 12/5/16 physical examination form did not include his/her seasonal allergy. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The Program Specialist, Medical Coordinator and Licensing Coordinator, will review all information in the ISP to ensure that it is correct. If the Medical Coordinator and/or Licensing Compliance find any discrepancies, these areas will be addressed with the Program Specialist who will then in turn inform the Supports Coordinator via email about said discrepancies. If needed, a meeting will be held with all team members to ensure all parties of the updates/revisions/corrections. Supports Coordinator was contacted to include the allergy that was not listed in this particular ISP. (Attachment #14) |
01/20/2017
| Implemented |