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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(e)(1) | Individual #2's assessment, completed 11/24/2024, did not include the individual's preferences. This section was left blank.
Individual #3's assessment, completed 6/27/2024, did not include the individual's preferences. This section was left blank.
Individual #4's assessment, completed 9/26/2024, did not include the individual's preferences. This section was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | On 1/30/2025, all program specialists were trained on how to complete each section of the Vocational Assessment Form by the Quality Assurance Specialist and Program Specialist Coordinator. Training is documented in their Relias training records. Individual 3 and Individual 4¿s vocational assessments preference sections were updated on 2/3/2025 and mailed to the appropriate individual¿s team members. Individual 2 had been discharged at the time of inspection; therefore no corrections to his file were possible. Program Specialists are responsible for reviewing all of their current vocational assessments for completeness and making any further corrections needed by 2/28/2025. These corrections, if any, will be documented within the individuals¿ files. |
02/13/2025
| Implemented |
| 2390.152(a) | Individual #1, date of hire 2/28/2024, has not had an Individual Service Plan completed by a Program Specialist.
Individual #2, date of hire 9/26/2023, has not had an Individual Service Plan completed by a Program Specialist.
Individual #5, date of hire 6/17/2019, has not had an Individual Service Plan completed by a Program Specialist. | The program specialist shall coordinate the development of the individual plan, including revisions with the client and the individual plan team. | On 1/31/2025, BCRC¿s executive director and quality assurance specialist received Technical Assistance from the licensing inspector including the relevant regulations. The technical assistance was shared with the Mental Health Program Coordinator and Manager of Mental Health Services. A meeting was held on 2/7/2025 with the Executive Director, Manager of Mental Health Services, and Mental Health Program Coordinator. Procedures were developed for the Individual Plan process for all current Handicapped Employment participants and all new admissions who do not otherwise have an ISP developed by an outside entity. On 2/10/2025, the Quality Assurance Specialist created a Meeting Attendance Form, ISP Meeting Invitation Letter, and ISP template with content guidelines and shared with the MH Program Coordinator. The MH Program Coordinator and Mental Health Services Administrative Assistant and Quality Assurance Specialist then met to develop tools to use as reminders for program, clerical and compliance tasks. A schedule has been developed for all 14 remaining individuals¿ required ISP processes to be followed and in effect by 9/30/2025 according to individual needs and availability.
An ISP meeting for Individual 5 for 3/12/2025. This date provided time for the individual plan process to be followed, including for his vocational assessment to be updated at least 30 days prior to the meeting, a meeting to be held, and then for the ISP to be finalized after the meeting to go into effect.
Individual 2 had been discharged at the time of inspection; therefore, no corrections to his file were possible. We were informed on 2/12, that Individual 1 was changing funding streams from the mental health county base funding to intellectual disability waiver funding effective as of 1/17/25 and therefore would have an ISP developed by his Supports Coordinator. |
02/13/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.151(a) | Individual #1's assessment, completed 10/21/2022, indicated that they could independently use or avoid poisonous materials. Individual #1's Individual Support Plan, last updated 2/28/2023, indicated that they should be monitored around poisonous substances due to an increase in dementia. | Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual #1 in question had their Assessment updated on March 7, 2023 to reflect the change documented in the violation. A selection of Annual Assessments completed in the previous quarter by this staffer will be audited to ensure that this was a one-time mistake and not a trend. Staff in question will receive re-training on the Annual Assessment process if any additional issues are found. |
03/08/2023
| Implemented |
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