| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(4) | Individual #1's need for supervision is not clear. The behavioral plan states unsupervised time in bedroom with checks every half hour; the Individual plan states 15 minutes unsupervised time when she is calm. The assessment states 1:1 with no unsupervised time. | The assessment must include the following information: The individual's need for supervision.
| The individuals area of assessment has been updated to show the progress over the last 365 days and her current level of supervision needs. 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 #3, #6, #7, #8) |
07/06/2021
| Implemented |
| 6400.181(e)(7) | Individual #1's 1/6/2021 assessment does state her knowledge of the danger of heat sources; however, fail to mention her ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The individuals area of assessment has been updated to show the progress over the last 365 days and her current level in regards to heat sources. 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 #3, #6, #7, #8) |
07/06/2021
| Implemented |
| 6400.211(b)(1) | There was no name, address, and phone number of a designated contact from Superior Human Services to be contacted in case of an emergency for individual #1. The contact in case of an emergency information only listed "Superior Human Services" in general, instead of a specific contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| The medical coordinator is responsible for ensuring that all areas of the CLA are filled in and that SHS must not be listed but a responsible parties name must be listed. This documentation will be reviewed at least quarterly and updated as needed. The CEO has meet with the Medical Coordinator and has trained her on this regulation. (Attachment #3, #10) |
07/06/2021
| Implemented |
| 6400.185(1) | Individual #1's 1/3/2020 Individual Plan does state her knowledge of the danger of heat sources; however, fail to mention her ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Also, individual #1's current behavioral plan states she needs to be eating a high fiber diet and drinking a lot of water. This is not mentioned anywhere else in her documentation, including her individual plan. Individual #1's 12/21/2020 physical states she is to follow a regular diet. Individual #1's need for supervision is also not clear. The behavioral plan states unsupervised time in bedroom with checks every half hour; the Individual plan states 15 minutes unsupervised time when she is "calm". There is no definition of "calm" given in the behavioral plan. The assessment states 1:1 with no unsupervised time. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs. | The individuals ISP, Assessment, and BSP have been reviewed and all information has been updated with the correct information for heat sources, supervision, dietary needs as well as the explanation of what calm means in this individual plans. This information was shared with her team and staff have been trained on her plans. Attachment #3, #6, #7, #8) |
07/06/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's face sheet did not indicate her religion status. It was left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The medical coordinator is responsible for ensuring that all areas of the CLA are filled in and that SHS must not be listed but a responsible parties name must be listed. This documentation will be reviewed at least quarterly and updated as needed. The CEO has meet with the Medical Coordinator and has trained her on this regulation. (Attachment #2, #10) |
07/06/2021
| Implemented |