| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.59 | The telephone number of the nearest hospital was not posted by the telephones located in the conference room, program area and copy area. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone | The hospital telephone number was added to the emergency list and posted by each telephone before the inspector left the site on august 19th. [CEO or designee will monitor telephones in the facility at least quarterly to ensure required phone numbers are on or by each phone. (AS 10-1-15) |
09/24/2015
| Implemented |
| 2390.87 | Direct Service Worker #1, date of hire 12/3/14, had initial training in general fire safety and in the use of fire extinguishers 12/18/14. | Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept. | This direct service worker was hired on 12/3/14 and started working as a home and community habilitation specialist. The employee's first day of work at the vocational facility was 12/18/14. Employee records have been modified to include the employee's hire date with the agency but to also include the date the employee began work in the facility as these 2 dates are not always the same. The program director will ensure that all facility employees complete all required trainings before starting to work on the floor. |
09/24/2015
| Implemented |
| 2390.124(1) | The records for Individual #1, date of admission 3/17/15, and Individual #2, date of admission 4/19/11, did not include birthplace. | Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge. | Program specialists were re-trained in ensuring all paperwork is completed in its entirety and that no information is left blank. In the event that information is unknown, it is the responsibility of the program specialist to contact team members to obtain required information. The program director will be responsible for reviewing all paperwork to ensure it is completed in its entirety. Program Director also reviewed all unaudited files to ensure all information was included. |
09/24/2015
| Implemented |
| 2390.151(a) | Assessments for Individual #2 were completed 12/17/13 and 1/6/15. | 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. | Program specialists were re-trained in the importance of complying with time frames for initial and annual assessments. A color coded tracking chart has been developed for each program specialist outlining the dates that annual assessments are due for each of their clients. File reviews will be completed by the program director to ensure compliance with the timelines. |
09/24/2015
| Implemented |
| 2390.156(a) | An ISP review was completed with Individual #2 on 10/6/14 and on 2/3/15. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | The quarterly was completed in a timely fashion however could not be signed by the client due to client being out of the program for 4 weeks. The program specialists have been re-trained to note the service interruption and date of return in the report to justify the signature date. |
09/24/2015
| Implemented |
| 2390.156(d) | The ISP reviews for Individual #1, completed on 4/21/15 and 7/14/15 were not sent to the plan team members. The ISP reviews for Individual #2, completed on 10/6/14, 2/3/15, 4/7/15 and 7/13/15 were not sent to the plan team members. The ISP review for Individual #3, completed on 7/8/15 was not sent to the plan team members. The ISP reviews for Individual #4, completed on 10/6/14, 1/12/15, 4/8/15 and 7/14/15 were not sent to the plan team members. The ISP reviews for Individual #5, completed on 10/6/14, 1/9/15, 4/2/15 and 7/8/15 were not sent to the plan team members. The ISP reviews for Individual #6, completed on 10/6/14, 1/12/15, 4/2/15 and 7/8/15 were not sent to the plan team members. | The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The quarterlies were sent to all team members however there was no documentation proving that they were sent. A form for each individual was developed to record to whom and the date the information was sent. The form also includes the method by which it was sent (mail, email or fax). Program specialists were trained in the utilization of this form and the Program Director will review the forms to ensure they are being completed. |
09/24/2015
| Implemented |