| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The written emergency evacuation procedure did not include the individuals and staff responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Who: Assistant Director of ID Services
What: Updated the form to include all regulatory requirements.
When: After form was found to be out of compliance with regulations.
How: Form was updated after licensing. All staff and individuals were trained in their responsibilities in the event that an evacuation must occur at one of the group homes. A copy of the form that was individualized for each individual, was placed in the individual¿s records at the home.
Attachments:
¿ Copy of the Emergency Relocation Plan for each individual (attachment # 1)
¿ Signature showing that all staff and all individuals were trained in their responsibility (attachment # 2) |
09/19/2016
| Implemented |
| 6400.181(e)(10) | Individual #1's 4/18/16 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that the life time medical history is included with the assessment.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: Please note that the Assessment always contained a Lifetime Medical History, and the assessment clearly stated that the life time medical history was done with the assessment, but at the time of licensing, the manner in which we file our paperwork showed that the assessment was filed in 2 separate sections. Additionally, the letter sending out the assessment did not state that the lifetime medical history was ¿part of the annual assessment. Plan of correction was to update the cover letter sending the assessment to the team members now states: ¿Enclosed, please find a copy of (individuals¿ name) Annual Assessment that include the Lifetime Medical History that was completed on (date).
Attachments:
¿ Copy of updated cover letter that shows changes. (attachment # 13)
¿ Copy of annual assessment that shows that annual assessment states that
`although the complete medical history may be separated from the annual assessment, the complete medical history is the last part of the annual assessment. The reason the information is separate is because the information is sent to the individual¿s Primary Care Physician for review¿ (attachment # 13 )
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12) |
09/19/2016
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include an assessment of 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. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulated information is included in the ISP
When: At Annual Review Meetings and as needed.
How: A checklist was developed to ensure that all regulated aspects of the ISP are present. You will utilize this form during the Annual Review Meeting and also utilize this form when the ISP is finalized to ensure that all necessary information is included, since the SC is the party responsible to type the ISP.
Attachments:
¿ Email from PC to Supports Coordinator requesting information be added to Individual #1¿s ISP. (attachment #25)
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of new checklist that has been implemented (attachment # 26) |
09/19/2016
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) did not include an assessment of 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.
| Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulated information is included in the ISP
When: At Annual Review Meetings and as needed.
How: A checklist was developed to ensure that all regulated aspects of the ISP are present. You will utilize this form during the Annual Review Meeting and also utilize this form when the ISP is finalized to ensure that all necessary information is included, since the SC is the party responsible to type the ISP.
Attachments:
¿ Email from PC to Supports Coordinator requesting information be added to Individual #1¿s ISP. (attachment #25)
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of new checklist that has been implemented (attachment # 26) |
09/19/2016
| Implemented |