Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00113655 Renewal 06/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.101Individual # 1's record did not included communicable disease authorization. Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician.The physical examination obtained from the SC on 6/21/17 (see citation 390.124(5)) does not include a statement regarding communicable diseases for the individual. Individual 1 has no symptoms of communicable diseases as defined in 101, so we have asked for clarification regarding the exact requirement to meet the regulation. Program Specialists were trained by the MH/ID Compliance Monitor on the regulation on 6/28/17, including a general review of agency procedures for handling any person who does exhibit symptoms, which include sending the individual home and requiring medical clearance prior to the person's return to the site. Program Specialist for Individual 1 is contacting the residence for the client to get a copy of their physical of the person by 6/30/17; anticipating the 6400 regulations require the communicable disease statement. Program Specialists are reviewing all active client files for information regarding the individual's status in relation to communicable diseases. File review to be completed by 7/21/17. 07/21/2017 Implemented
2390.124(5)Individual # 1's record did not contain a physical examinationEach client's record must include the following information: Physical examinations.Documentation of the most recent physical examination for Individual #1 was obtained from the supports coordinator on 6/21/17. Staff were retrained by the MH/ID Compliance Monitor regarding the regulation on 6/28/17; including a review of the file index as a checklist for determining required documents. Program Specialists are reviewing all open files to insure there is a physical examination in the file for the individual, review to be completed by 7/21/17. 07/21/2017 Implemented
2390.156(c)(2)Repeated Violation (06/28/16) -Individual # 1's Individual Support Plan (ISP) last updated 10/18/16 indicates SEEN plan when working at GoodWill. Individual # 1's quarterly review dated 0202/17 did not review SEEN plan The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The program specialists were reinstructed by the MH/ID Compliance Monitor on 6/28/17 regarding the requirement to review each section of the ISP specific to our services, as well as a review on the format of the quarterly form itself to insure they understand each item. The quarterly form has been revised by the MH/ID Compliance Monitor, to include more explicit instructions regarding the requirement. The revised form is in use effective 6/28/17; although there have been no quarterly reviews scheduled to date. Program Specialists are reviewing all client files to insure the quarterly reviews address all specialized plans for the individual; target date for completion of file review 7/21/17. 07/21/2017 Implemented
SIN-00094914 Renewal 06/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61Men's bathroom that is closest to the shredding area, a large piece of cement on the floor (left side across from sinks) is broken. Also, the men's bathroom on the first floor near the deep storage area, there is rust and chipped paint all along the wall underneath the radiator; the bathroom door is missing paint and it is rusted on the outside.  Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.Maintenance request was made immediately after the site inspection. Some repairs are completed, the rest will be completed by July 30, 2016. MH/ID Compliance Monitor met with staff who conduct monthly facility inspections to retrain them on the regulatory requirements. 07/05/2016 Implemented
2390.124(10)Individual number 2's record did not contain a current copy of the ISP. Each client's record must include the following information: A copy of the current ISP.A copy of the ISP was placed in the file by the MH/ID Compliance Monitor on July 12, 2016. All client files were reviewed to ascertain if the current ISP's were in the records. The file review checklist was updated to reflect the requirements and program specialists are conductive case file reviews under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor. 07/12/2016 Implemented
2390.124(12)Individual number 3 current physical states he has an allergy to Lisinopril. Individual number 3 intake documentation states he has no known allergies. Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under §  2390.156.The intake information was completed on 2/5/15 and at that time, #3 had no known allergies; this is confirmed by his ISP for 14-15 and 15-16. The allergy to Lisinopril was first identified in early 2016 and was included on the physical dated 2/25/16, again, confirmed by the 16-17 ISP. The program specialist on 7/1/16 confirmed that the information is correct. It is not common practice to update original intake documents as that is considered historical documentation of that point in time. 07/01/2016 Implemented
2390.151(e)(2)In individual number 1's 3/7/16 Assessment does not include his dislikes. The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client.An addendum has been attached to the assessment to include his dislikes. All files have been reviewed for compliance. The file review checklist has been updated to better reflect the requirements. Program Specialists are conducting regular file reviews with the checklist, under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor, to insure continued compliance. 07/28/2016 Implemented
2390.153(4)Individual number 3 current ISP does not address his supervision needs in the facility or on the premises of the facility. It also does not include the ratio of individuals per supervisor. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence.The program specialist contacted the SC on 7/20, requesting that the information be included in the ISP. All client files have been reviewed for the required information. The file review checklist has been updated to specifically include the supervision requirements; and the program specialists are conducting regular case file reviews under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor. 07/20/2016 Implemented
2390.153(5)There is no SEEN plan in place for individual number 3. Individual number 3 is prescribed a psychotropic medication. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.Individual 3 has an abbreviated version of the SEEN plan in his ISP; but the Goodwill record did not have a copy of the plan in entirety. The program specialist contacted the SC requesting a copy on 7/20/16 with a follow up call on 7/26/16, and another email on 7/28/16. The file review checklist has been updated to better reflect the requirements. Program Specialists are conducting regular file reviews with the checklist, under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor, to insure continued compliance. 07/28/2016 Implemented
2390.156(a)Individual number 4's 4th quarterly review was late; dated 3/30/16 and previous quarterly dated is 11/30/15. An ISP review due by 6/14/16 was not completed for individual number 2. 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 for #2 has been completed. The file review checklist has been updated to more specifically address the due dates for quarterly reviews. Program Specialists are conducting regular file reviews with the checklist, under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor, to insure continued compliance. 07/28/2016 Implemented
2390.156(c)(1)The following monthly documentation was missing from individual number 2's record: January 2016 through May 2016. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.Monthly documentation was completed for #2 file for the missing months and has been brought current to July 2016. The file review checklist has been updated to better reflect the requirements. Program Specialists are conducting regular file reviews with the checklist, under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor, to insure continued compliance. 07/28/2016 Implemented
2390.156(c)(2)Individual number 3's 5/17/16 ISP review does not include a review of his SEEN plan. Individual #1 ISP review 4/6/16 did not contain a review of his SEEN plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The quarterly review format has been revised to include specific areas in which to address the SEEN plan, etc. as appropriate for the individual. The file review checklist has been updated to better reflect the requirements. Program Specialists are conducting regular file reviews with the checklist, under the supervision of the Manager of Community Based Services and the MH/ID Compliance Monitor, to insure continued compliance. 07/28/2016 Implemented
SIN-00073850 Renewal 04/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(13)(i)The assessment for Individual #4 did not contain progress and growth in 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.The Manager of Vocational Services has retrained the Program Specialists regarding the need for information in this section, including (example) routine medical assessments or appointments, general health stable, etc. The Program Specialist has attached an addendum with the required information and all Program Specialists have reviewed files for compliance. See Attachment 7. 08/07/2015 Implemented
2390.151(e)(13(ii)The assessment for Individual #4 and #5 did not contain progress and growth in 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.The Manager of Vocational Services has retrained the Program Specialists regarding the need for information in this section, including (example) expressive language and receptive language skills, manual dexterity, etc. The Program Specialist has attached addenda for both individuals with the required information and all Program Specialists have reviewed all files for compliance. See Attachments 7 & 8. 08/07/2015 Implemented
2390.151(e)(13)(iii)The assessment for Individual #4 did not contain progress and growth in 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.The Manager of Vocational Services has retrained the Program Specialists regarding the need for information in this section, including (example)the ability to interact with others in the work site or with supervisors, etc. The Program Specialist has attached an addendum with the required information and all Program Specialists have reviewed all files for compliance. See attachment 7 08/07/2015 Implemented
2390.151(e)(13(iv)The assessment for Individual #4 did not contain progress and growth in 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.The Manager of Vocational Services has retrained the Program Specialists regarding the need for information in this section, including (example) ability to socialize appropriately in a work setting, general social skills etc. The Program Specialist has attached an addendum with the required information and all Program Specialists have reviewed all files for compliance. See Attachment 7. 08/07/2015 Implemented
2390.151(e)(13)(v)The assessment for Individual #4 and #5 did not contain progress and growth in vocational 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: (v) Vocational skills.The Manager of Vocational Services has retrained the Program Specialists regarding the need for information in this section, including (example) ability to work independently, work tolerance, etc. The Program Specialist has attached addenda to the assessments for both individuals with the required information. Program Specialists have reviewed all files for compliance. 08/07/2015 Implemented
2390.153(5)There was no protocol to address the social, emotional, and environmental needs for Individual #5. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program Specialist has made two requests to the supports coordinator asking that the SEEN plan be included in the ISP. See attachment 2390.153(5). The MH/ID Compliance Monitor and the Manager of Vocational Services have retrained the program specialists on the requirement that the SEEN plan must be included in the ISP itself. The Program Specialists are reviewing all files to determine if SEEN plans are missing from other ISP(s) in order to make the necessary requests to the Supports Coordinators. This will continue to be an area of focus in the ongoing file review done by the Program Specialists and the Manager of Vocational Services. 09/30/2015 Implemented
2390.153(7)(ii)The Individual Support Plan (ISP) for Individual #5 did not contain an assessment of the client's potential to advance in community-integrated employment. The ISP, including annual updates and revisions under §  2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment.The Program Specialist has contacted the Supports Coordinator regarding the need for an assessment of the individual's potential to advance in community-integrated employment and also sent a written assessment for inclusion. The Manager of Vocational Services trained the Program Specialists regarding the need for the assessment as part of the ISP as well as the need to review the ISP when received to make sure all requirements are met. The program Specialists are reviewing all ISP(s); if the section is missing from others, the Program Specialists will provide the necessary information to the Supports Coordinator. 08/28/2015 Implemented
2390.156(a)Individual #4 had an Individual Support Plan (ISP) review completed on 5/14/14 and not again until 9/12/14, outside of the 3 month time frame. 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.Individual 4 had a quarterly review on 8/21/14 in the file, which was overlooked. A copy of the review is included in the supporting documentation. 07/31/2015 Implemented
2390.156(b)Individual #5 did not date the Individual Support Plan (ISP) review completed on 6/2/14. The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.The MH/ID Compliance Monitor reviewed the file and added the correct date, since case notes provided information as to when the review was presented to the client. The Manager of Vocational Services retrained the Program Specialists regarding the requirement that all signatures be dated. The Program Specialists have reviewed all client files for signatures and dates and made the necessary corrections. The Program Specialists and the Manager of Vocational Services are reviewing files for compliance on an ongoing basis. 08/04/2015 Implemented
2390.156(c)(1)The Individual Support Plan (ISP) review for Individual # 5 completed on 8/12/14 did not include a review of their monthly participation and progress towards their ISP outcome. The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.The program specialist has added an addendum containing the review of the monthly documentation toward the outcomes. The Manager of Vocational Services has retrained the Program Specialist regarding the requirement that monthly documentation must be reviewed on every quarterly review. Program Specialists have reviewed all client files and included addendums as necessary. See attachment 4 2390.156(c)(1) 08/10/2015 Implemented
2390.157The Individual Support Plan (ISP) meeting for Individual #5 was held on 8/12/14. The ISP was not approved and sent to team members until 1/22/15.A copy of the ISP, ISP annual update and ISP revision, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, ISP annual update and ISP revision meetings.The Manager of Vocational Services retrained the Program Specialists regarding the need to document requests to the SC for the ISP within the 30 day time frame. Program Specialists are now requesting the ISP on the day of the meeting as suggested. The Manager of Vocational Services is checking files for compliance on an ongoing basis. 08/04/2015 Implemented
SIN-00060270 Renewal 02/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)* REPEAT The intial assessment for Individual #1 was not completed 60 calendar days after her admission. There was no assessment for Individual #1 in the records. (a)  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.4/11/14 CSS Partially Implemented/Adequate Progress 1. Program Specialists were reinstructed on the requirements in a meeting on 3/7/14. See Sign in sheet. Staff having particular difficulty meeting the regulatory requirements received/will receive specific performance plans to insure the standards are met. 2. Program Specialists will immediately begin using the checklist with each file to track documentation due dates throughout the year. (see checklist) 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Supplemental documentation will be sent via email. 05/01/2014 Implemented
2390.151(f)*REPEAT The Annual Assessment for Individual#5 was not sent to the plan team members at least 30 days prior to an ISP meeting. The annual assessment was dated for 12/20/13 and the ISP meeting was held on 12/10/13. The assessment was sent to plan team members after the ISP meeting. 4/11/14 CSS Partially Implemented/Adequate Progress (f) The program specialist shall provide the assessment to the SC or plan lead, 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).1. Review of the file after the inspection revealed that the assessment was actually sent out on 11/13/13, prior to the scheduling of the meeting. The SC scheduled the meeting at the ¿last minute¿ and then requested a second copy of the assessment which was sent on 12/20/13. Program Specialists were reinstructed on the requirements to have the assessment sent to team members at least thirty days in advance of the meeting. These instructions included: a. Notifying the SC that the meeting can not be scheduled with less than 33 days notice to allow the Program Specialist to meet the requirement for the assessment to be sent out at least 30 days in advance. b. Since most SC¿s schedule the annual ISP meeting at the third quarterly review, Program Specialists will complete the assessment in time to send it out 30 days in advance of that third quarterly review. 2. Program Specialists will immediately begin using the checklist with each file to track documentation due dates throughout the year. (see checklist) 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Supplemental documentation will be sent via email. 05/01/2014 Implemented
2390.154(c)The ISP meeting signature sheet for Individual #1 was not in the record. (c ) A plan team member who attends an ISP meeting under subsection (b) shall sign and date the signature sheet.4/11/14 CSS Partially Implemented/Adequate Progress 1. Program Specialists were reinstructed in the requirements on 3/7/14. See sign in sheet. These instructions included getting a copy of the ISP signature sheet from the SC prior to the end of the meeting. 2. Manager of Vocational Services will develop a checklist for the meeting requirements so staff can refer to it to insure that all necessary documentation is in place. 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Supplemental documentation will be sent via email. 05/01/2014 Implemented
2390.156(c)(1)Individual #1's record did not contain any monthly review documentation of participation and progress. (c ) The ISP review must include the following: (1) A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter.4/11/14 CSS Partially Implemented/Adequate Progress 1. Program Specialists were reinstructed on the requirements in a meeting on 3/7/14. See Sign in sheet. Staff having particular difficulty meeting the regulatory requirements received/will receive specific performance plans to insure the standards are met. 2. Program Specialists will immediately begin using the checklist with each file to track documentation due dates throughout the year. (see checklist) 3. Program Specialists will conduct weekly audits of each other¿s file using the licensing documentation checklist. Supplemental documentation will be sent via email. 05/01/2014 Implemented
SIN-00045701 Renewal 02/12/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual's #5 & 6 did not have a written assessment completed 60 days after admission to the facility.(a)  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.1. Program Specialists have been re-instructed on the requirement to complete the Initial assessment within 60 days of admission. (Completed) 2. First initial assessment for individual admitted after the licensing inspection has been completed and will be provided as documentation. 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 e. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2390.151(d)The assessments for Individuals' #2 & 6 were not signed and dated by the Program Specialist.(d)  The program specialist shall sign and date the assessment.1. Program Specialists have been re-instructed on the requirement of signing and dating all documentation. (Completed) 2. Program Specialists are reviewing all client documentation to ensure that necessary signatures are present. Files 2 and 6 have been corrected.(Target: 3/18/13) 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 e. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted 07/31/2013 Implemented
2390.151(e)(2)The assessment for Individual #6 did not include his like, dislikes, and interests.(e) The assessment must include the following information: (2) The likes, dislikes and interest of client, including vocational and employment interests of the client.1. There was a general Program Specialist training on completion of all sections of the assessment by the MH/ID Compliance Monitor. A sample assessment was created and provided to all Program Specialists. (Completed) 2. Program Specialists are reviewing all client documentation and will add any information missing from the original document as addendum. File 6 has been corrected. (Target: 3/18/13) 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 e. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2390.151(f)The assessment for Individual's #2, #6, and #1 were not sent to all Plan Team members.(f) The program specialist shall provide the assessment to the SC or plan lead, 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).1. The cover letter for sending assessments has been revised and all Program Specialists were instructed on use and maintaining copies of the letter as documentation the assessments were sent as required. The requirement of sending to all team members rather than just the SC was clarified. Copies of emails will be maintained in the file when that is the method of delivery. (Completed) 2. The signature sheet for the ISP meetings will be revised to include the date a copy of the assessment was sent to the individual team member. In the event a team member is new at the meeting, a copy will be provided at that time and documented on the sign in sheet. 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 d. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. Partially Implemented - Adequate Progress 07/31/2013 Implemented
2390.156(b)The June 2012 ISP review for Individual's #3 and the September and November 2012 ISP reviews for Individual #6 were not signed by the Program Specialist or the Individual.(b) The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP.1. Program Specialists have been re-instructed on the requirement reviewing the reports with the individual as well as the signing and dating all documentation. (Completed) 2. Program Specialists are reviewing all client documentation to ensure that necessary signatures are present. Any document that does not have the signature of the individual will be reviewed with that person immediately. (Target: 3/18/13) 3. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13 e. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13. 07/31/2013 Implemented
2390.156(e)The Program Specialist did not notify Individual #6's Plan Team members of their option to decline his ISP reviews(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation.1. The cover letters for reviews have been revised to clearly include the option to decline copies of reviews. Program Specialists have been re-instructed on the requirement of maintaining copies of the letter including declination in the client file. (Completed) 2. The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations: a. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13 b. Training of all Program Specialists in use of the checklist. Target: 4/15/13 c. Annual training in documentation for all staff. (In process) d. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4 /30/13 e. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director Partially Implemented - Adequate Progress 07/31/2013 Implemented