| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | No record of written summary of corrections in self-assessment complete 02/24/20. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. A Self-Assessment binder was assembled and each site has it's own section. 3. All Program specialists were trained/retrained on the purpose of the self-assessment, how to complete and where they will be kept on 3/12/2020.
4. Self-assessments will be completed in January and July of every year. This will be scheduled by the Compliance Officer (hired 7/28/19) and completed as a group with assistance. |
03/12/2020
| Implemented |
| 6400.112(c) | 05/17/19 fire drill record does not include the amount of time it took for the individuals to evacuate. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID management team. 2. All Direct Support Professionals were trained/retrained on Fire Safety and the requirements of fire drills on 3/11/2020.
3. All Program specialists were trained/retrained on on 3/12/2020 and Site Coordinators on 3/13/2020 on the requirements of fire safety.
4. All program specialists will review and initial the fire drill. If follow up action is required, copies of communication will be included with the unsuccessful fire drill. |
03/13/2020
| Implemented |
| 6400.141(c)(9) | The last attempted prostate exam was 07/03/18, when the physician stated that the exam could not be completed due to "Parkinson's and dementia", however, the physician did not indicate that Individual #1 suffered from either condition on the physical form itself or the attached "Current Diagnosis" list. There is a current diagnosis of an enlarged prostrate and no indication that a PSA test has ever been completed. | The physical examination shall include: A prostate examination for men 40 years of age or older. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the requirements for the prostate exam on 3/12/2020.
3. The individual had a PSA completed on 3/9/2020. |
03/12/2020
| Implemented |
| 6400.181(a) | Assessment completed 02/06/2020, no prior Assessments available. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020.
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individual's assessment was amended 3/25/2020. |
03/25/2020
| Implemented |
| 6400.181(e)(7) | Assessment does not address Individual #1 ability to move away from a heat source. | 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. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individual's assessment was amended 3/25/2020 to include ability to move away from heat source. |
03/25/2020
| Implemented |
| 6400.181(e)(10) | Lifetime medical history has not been updated with any information since July 2017. | The assessment must include the following information: A lifetime medical history. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020.
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individual's assessment was amended 3/25/2020 to update the lifetime medical history. |
03/25/2020
| Implemented |
| 6400.32(r) | There are no locks on individual room doors. | An individual has the right to lock the individual's bedroom door. | 1. Developed bedroom door lock education/determination/condition form to be completed for each individual. This is to be completed by 4/17/20.
2. Door locks will be installed on individuals' bedroom doors as soon as COVID-19 protections are lowered and visitation to homes is safer. Anticipated installation date by 6/30/2020. |
06/30/3030
| Implemented |
| 6400.44(b)(1) | Program Specialist has not coordinated the completion of Assessments in a timely or meaningful way. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | 1. Between January 14 - February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 4-10, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020.
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individual's assessment was amended 3/25/2020 to update the lifetime medical history. |
03/25/2020
| Implemented |
| 6400.44(b)(2) | Program Specialist has not updated the Medical History since July 2017, no plan reviews were conducted for the time period between 12/29/17 and 02/06/2020, and the most recent (and only available) Annual Assessment was not completed prior to the ISP meeting. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator, as well as ISP reviews on 3/12/2020.
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individuals's assessment was amended 3/25/2020 to update the lifetime medical history. 5. As of 4/14/2020, all monthly ISP reviews are up to date for this individual. By 4/30/2020, it is anticipated that all individuals records and monthly ISP reviews will be up to date. |
04/14/2020
| Implemented |
| 6400.46(d) | Staff #4 completed First Aid/CPR training on 03/07/17 and not again until 08/09/19.
Staff #5 completed First aid/ CPR training on 11/08/16 and not again until 03/21/19. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | 1. The Training and Workforce Development Officer (hired 3/25/19) has developed a spreadsheet using Conditional Formatting to provide alerts when staff training due dates are approaching. These alerts will be set-up to allow sufficient time to schedule the trainings. |
04/14/2020
| Implemented |
| 6400.169(b)(2) | Staff #4 completed diabetes training 10/30/17 and not again until 03/07/19.
Staff $5 completed diabetes training 06/29/17 and not again until 04/05/19. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | 1. The Training and Workforce Development Officer (hired 3/25/19) has developed a spreadsheet using Conditional Formatting to provide alerts when staff training due dates are approaching. These alerts will be set-up to allow sufficient time to schedule the trainings. |
04/14/2020
| Implemented |
| 6400.181(b) | Assessment not sent to ISP team 30 days prior to ISP meeting on 09/17/19. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020.
3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings.
4. The individual's assessment was amended 3/25/2020. |
03/25/2020
| Implemented |