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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the rotary telephone in the basement. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| 1. TLHHC did not realize that there was a live rotary phone in the basement. On 5/3/2018 CEO assigned staff to post emergency contact by the rotary phone in the basement. CCO will submit the picture of the corrected violation on 5/10/2018
2. On 5/4/2018 CCO added violation on 6400.71 to the monthly house inspection. CCO will submit the revised monthly inspection and Delmont's completed house inspection on 5/10/2018.
3. On 5/7/2018 All house Supervisors were notified about the addendum to the monthly inspection form, and used the form for their monthly inspection. CCO will submit House Supervisors' signatures and completed house inspection forms.
4. Program Specialist and/or QA/CO will conduct monthly random visit to the houses beginning 5/31/2018 and report the findings to CEO and Assessment Team. CCO will submit the outlook reminder on 5/10/18 and the random visit's findings on 6/4/2018
4. Agency put violation on 6400.71 on the agenda for 6/12/2018 Assessment Team meeting. The meeting agenda, minutes, and timesheet for 6/12/18 meeting will be submitted on 6/14/2018. The outlook reminder and agenda for the meeting on 6/12/2018 |
05/10/2018
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(f) | The initial assessment dated 10/12/15, for Individual #1, date of admission 9/12/15, was not provided to all team members, including the behavioral support provider. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Program Specialist will provide the annual 6400 assessments to all team members that are a paid service provider such as ATF, vocational facility and behavioral support. The Program Manager will receive the annual ISP assessment documentation to be sent and check that all team members as listed on the ISP meeting invitation letter are included. The Program Manager will return the documentation to the Program Specialist to be corrected before being sent. This procedural change was implemented as of 4/11/2016. [Individual #1's assessment dated 10/12/15 was sent to behavioral support provider on 4/28/16. Prior to providing assessment to plan team members, the program specialist will review all individual records including ISPs, invitation letter and other documentation to ensure the program specialist is providing the assessments to all team members as required. Documentation of correspondence to the plan team members shall be kept and reviewed by the CEO for at least 1 year to ensure the all team members are provided the assessments as required. Documentation of reviews shall be kept. (AS 5/26/16)] |
04/11/2016
| Implemented |
| 6400.186(d) | The initial 3 month review, for Individual #1, dated 12/31/15, was not sent to all team members, including the behavioral support provider. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The Program Specialist will provide the three month ISP review documentation within 30 calendar days of the ISP review meeting to all team members that are a paid service provider such as ATF, vocational facility and behavioral support unless said providers (except SC) decline to receive the documentation. The Program Manager will receive the ISP review documentation to be sent and check that all team members as listed on the ISP meeting invitation letter are included unless there is documentation that providers have declined. The Program Specialist attended ISP meeting for CS on 4/12/2016 and received signed declination paperwork from one vocational program. The Program Specialist sent the ISP review to all remaining members of the team. A copy of the declination page and the ISP review page has been filed at the office in a 2016 POC folder. This procedural change was implemented as of 4/11/2016. [Individual #1's ISP reviews were sent to plan team members on 4/28/16. Prior to providing ISP reviews to plan team members, Program Specialist will review all individuals' invitation letters, ISPs and other documentation to ensure all team members for all individuals are provided ISP review documentation as required. Documentation of correspondence to the plan team members shall be kept and reviewed by the CEO for at least 1 year to ensure the all team members are provided the ISP reviews as required. Documentation of reviews shall be kept. (AS 5/26/16)] |
04/11/2016
| Implemented |
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