| 6400.141(a) | Individual #1 had a physical examination completed on 6/24/15 and then again on 8/5/16. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This individual did have a physical exam on 8/5/16 but not within 12 months. Our corrective action moving forward is that house managers will complete a monthly quality check of physical examinations. Program Specialists will complete a quarterly quality check of physical examinations. Residential Directors will review a representative sample of physical examinations. Evidence of this sample review will be saved in SharePoint. [Immediately, the CEO or designate management staff person shall develop and implement a tracking system to ensure all individuals have a physical examination within 12 months prior to admission and annually thereafter and educate house manager, Program specialists of the tracking system. At least quarterly for 1 year, the program specialist shall complete a review of a 10% sample of current physical examinations to ensure timely completion. At least quarterly for 1 year the residential director shall review the tracking system to ensure completion and that all individuals have physical examinations within 12 months prior to admission and annually thereafter. Documentation of tracking system and reviews shall be kept. (AS 7/12/17)] |
06/22/2017
| Implemented |
| 6400.186(d) | The program specialist provided the ISP review documentation end-dated 1/31/17 to the plan team members on 3/8/17. | 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 provided the ISP review documentation to plan team members. ODP reviewers were able to confirm this. Moving forward our corrective action is that Residential Directors will complete a quarterly review of documents required for ISP reviews. The documentation of this review will be saved in SharePoint. [Immediately, the CEO or designated management staff person shall educated the Program specialist(s) on their responsibilities as per 6400.186(a)-(e). Documentation of education shall be kept. Immediately the CEO or designated management staff person shall develop and implement a system to ensure the program specialist(s) provide individuals' ISP review documentation for all individual to plan team members as required, timely and documentation of correspondence is kept. At least quarterly, for 1 year the Residential Director or designated management staff person shall review a 10% sample of correspondence showing the program specialist provided individuals' ISP reviews to plan team members as required. Documentation of reviews shall be kept. (AS 7/12/17)] |
06/22/2017
| Implemented |