| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Repeat 8/22/16: Fire drill record dated 5/18/17 did not indicate whether or not the alarm was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All Supervisors are responsible for completing fire drills monthly. They then turn the fire drill form into the Program Specialist for approval. A new check off form was completed to ensure that all sections of the fire drill form are completed. The Fire drill and the check list will then be turned into the Chief Programming Officer for final approval.
All Program Specialists will start using this form November 1, 2017.
The Arc is currently looking into software that that fire drill form will be on a form that the supervisor can not go to the next section with out other sections being completed to prevent further sections being missed in the future. |
10/11/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's Tuberculin skin test was completed on 9/20/13 and not again until 10/19/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | All Supervisors and Program Specialists were retrained on regulation 141 (c) (6). Supervisors are responsible for competing a monthly medical and ISP tracking sheet. This is then checked by the Program Specialist monthly. This also should be monitored bi-yearly during the self-assessment. the Program Specialist assigned to that location is responsible for the self assessment completion and overseeing the team completing the self-assessment. Individual #1 next physical and TB are scheduled for October 18 and was completed, it is attached with the previous physical. |
10/18/2017
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| All Program Specialists were retrained to ensure the progress and growth in the health section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the areas of motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | All Program Specialists were retrained to ensure the progress and growth in the communication section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(iii) | Repeat 8/22/16: Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | All Program Specialists were retrained to ensure the progress and growth in the activities of residential living section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(iv) | Repeat 8/22/16: Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | All Program Specialists were retrained to ensure the progress and growth in the personal adjustment section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(v) | Repeat 8/22/16: Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | All Program Specialists were retrained to ensure the progress and growth in the socialization section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | All Program Specialists were retrained to ensure the progress and growth in the Recreation section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| All Program Specialists were retrained to ensure the progress and growth in the financial independance section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(viii) | Repeat 8/22/16: Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | All Program Specialists were retrained to ensure the progress and growth in the management of personal property section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.181(e)(13)(ix) | Repeat 8/22/16: Individual #1's annual assessment dated 3/2/17 did not include progress and growth over the last 365 calendar days in the area of community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | All Program Specialists were retrained to ensure the progress and growth in the community integration section are adhered to annually and updated as need to be in addendum form and they will be responsible for this information. A updated Assessment checklist and assessment will now include the regulation for the assessment sections. All program specialists will use this going forward starting November 1, 2017. Brian Y.' s team members were sent the addendum to reflect those updates. |
10/11/2017
| Implemented |
| 6400.213(11) | Repeat 8/22/16: Individual #1's plan of support dated 6/16/17 states staff are to follow the restrictive procedure plan. Individual #1's Individual Support Plan updated on 5/30/17 states there is no restrictive procedure plan in place and it was discontinued on 12/4/13. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Program Specialists are responsible for updating the Plan of Support and Restrictive plan annually and as needed. All Program Specialist were retrained and the Plan of Support for Individual #1 was updated to no longer reflect the restrictive pan since it is no longer valid and in effect. |
10/12/2017
| Implemented |