| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(13)(iii) | The most recent assessment dated 10/16/20 did not indicate individual #1's progress over the last year in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The individuals area of assessment has been updated to show the progress over the last 365 days and his current level in activities of residential living. This information was shared with his supports coordinator as well as an interested parties. This assessment was done by reviewing progress notes, visual assessment, as well as and interviews with both the individual and the staff that supports them. Both the program specialist and the assistant program specialist has reviewed the 6400 regulations with the CEO in regards to this regulation. (Attachment #2 and #3) |
07/06/2021
| Implemented |
| 6400.181(e)(13)(v) | The most recent assessment dated 10/16/20 did not indicate individual #1's progress over the last year in the area of 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. | The individuals area of assessment has been updated to show the progress over the last 365 days and his current level in regards to socialization. This information was shared with his supports coordinator as well as an interested parties. This assessment was done by reviewing progress notes, visual assessment, as well as and interviews with both the individual and the staff that supports them. Both the program specialist and the assistant program specialist has reviewed the 6400 regulations with the CEO in regards to this regulation. (Attachment #2 and #3) |
07/06/2021
| Implemented |
| 6400.181(e)(13)(vi) | The most recent assessment dated 10/16/20 did not indicate individual #1's progress over the last year in the area of recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The individuals area of assessment has been updated to show the progress over the last 365 days and his current level in regards to recreational activities. This information was shared with his supports coordinator as well as an interested parties. This assessment was done by reviewing progress notes, visual assessment, as well as and interviews with both the individual and the staff that supports them. Both the program specialist and the assistant program specialist has reviewed the 6400 regulations with the CEO in regards to this regulation. (Attachment #2 and #3) |
07/06/2021
| Implemented |
| 6400.181(e)(13)(ix) | The most recent assessment dated 10/16/20 did not indicate individual #1's progress over the last year in the area of community integration | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The individuals area of assessment has been updated to show the progress over the last 365 days and his current level in community integration. This information was shared with his supports coordinator as well as an interested parties. This assessment was done by reviewing progress notes, visual assessment, as well as and interviews with both the individual and the staff that supports them. Both the program specialist and the assistant program specialist has reviewed the 6400 regulations with the CEO in regards to this regulation. (Attachment #2 and #3) |
07/06/2021
| Implemented |
| 6400.20(a)(1) | The most recent ISP and assessment state that knives are locked due to an incident when Individual #1 took and hid a knife that the staff had laying out on a table. An incident analysis was not completed | The home shall complete the following for each confirmed incident: Analysis to determine the cause of the incident. | In future incidents of this nature, an incident analysis will be conducted by the behavior specialist and will be shared with the individual¿s team. This analysis will be updated quarterly to ensure that the most current information is part of the individual¿s plan. |
07/06/2021
| Implemented |
| 6400.20(b) | According to staff, the "knife incident" (individual #1 took a knife the staff had laying on the table and hid it. when staff asked individual why he hid the knife, he responded, "i don't know") happened over 3 years ago, but the knife incident is still being reported in the ISP and assessments as if it were a recent event and thus knives are kept locked. A quarterly trend analysis was not conducted to monitor this incident to assess whether this incident remains as a current concern for individual #1 or if it should be documented as the individual having a "history of". | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | In future incidents of this nature, an incident analysis will be conducted by the behavior specialist and will be shared with the individual¿s team. This analysis will be updated quarterly to ensure that the most current information is part of the individuals plan. The individual¿s assessment has been updated. The ISP has been reviewed as well and all information was updated and both the assessment and the updated ISP information was sent to the supports coordinator. (Attachment #3) |
07/06/2021
| Implemented |
| 6400.182(c) | The individual plan and the assessment must be congruent. The most recent assessment dated 10/16/2020 and the most recent ISP dated 6/2/2021 does not indicate individual #1's status on returning to the day center that was attended pre-COVID. The PS indicated that the individual does not want to currently return in the update sent to the SC however it does not indicate if this is temporary or permanent.
Also
The most recent ISP dated 6/2/2021 states that individual #1 has had "increased paranoia over the past year" however, the most recent psychiatric appointment dated 5/27/21 notates increased stability over the past year and a decrease in psychotropic medication of "abilify". | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The ISP has been updated and sent to the Supports Coordinator as well as an updated assessment. The individual has chosen not to go back to any day services and this has been changed in his ISP. Quarterly reviews of the assessment, ISP, and any other plans will be done by the program specialist and the assistant program specialist. (Attachment #5) |
07/06/2021
| Implemented |