| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.40(a) | Staff #2 never received training in relation to orientation to daily operations of the facility. | A facility shall provide orientation for staff relevant to their appointed positions. Staff shall be instructed in the daily operation of the facility and policies and procedures of the agency. | A facility shall provide orientation for staff relevant to their appointed positions. Staff shall be instructed in the daily operation of the facility and policies and procedures of the agency. The facility director will provide orientation to staff #2 to the daily operations of the facility. New staff will be provided orientation the first day of working in the facility. |
02/12/2018
| Implemented |
| 2390.51 | Individual #4 is legally Deaf and unable to hear the fire alarm system. The first aid area, lunch room and female's restrooms were not equipped with strobe lights. The licensed work area was not equipped with strobes visible to Individual #4. | For facilities serving physically handicapped clients, accommodations such as ramping and wide doorways shall be made to ensure the maximum physical accessibility feasible for entrance to, movement within, and exit from the facility, based upon each client's physical characteristics. | For facilities serving physically handicapped clients, accommodations such as ramping and wide doorways shall be made to ensure the maximum physical accessibility feasible for entrance to, movement within and exit from the facility based upon each client¿s physical characteristics. Individual #4 is legally deaf and unable to hear the fire alarm system. A personal tactile signaler and alert transmitter have been purchased (on 2/6/2018) for this individual to use while at day program. This device will be installed and Program director will provide staff and individual #4 with training on the use of the Personal Tactile Signaler by 4/2/18. |
04/02/2018
| Implemented |
| 2390.63 | The patio egress was not equipped with a light. | Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents. | Rooms, hallways, stairways, outside steps, porches and ramps shall be adequately lighted to assure client safety and avoid accidents. The facility director requested (on 3/2/2018) a light be installed on the patio egress by 4/2/2018. |
04/02/2018
| Implemented |
| 2390.112(b) | Upon Individual #1's date of admission, 4/3/17, he/she did not receive written information about his/her benefits. | Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. | Upon admission, a client must be given written information outlining working hours, benefits, leave policy, civil rights, grievance procedures, and benefits (for vocational facilities). The facility director provided a letter to individual #1 (on 3/9/18) detailing benefit information in writing. The facility director has updated the admissions letter to reflect benefits offered. |
03/09/2018
| Implemented |
| 2390.123 | All individuals' monthlies, that included their names, daily goal charts, outings, etc., were left unlocked and accessible on the floor supervisors' desks in the program area. | Information in the client records shall be kept confidential. Client records shall be kept locked when unattended. | Information in the individual files must be kept confidential. The individual files must be kept locked when unattended. The individual information (specific to attendance) was re-coded to not contain confidential information (full name). The individual information (specific to jobs completed) will be filed inside the supervisor's binder and locked while unattended. Supervisor floor staff will be trained on 3/6/18 regarding locking away client confidential information while unattended. All staff will be retrained on this requirement related to confidential information with 30 days of receipt of this plan. Staff training as well as monthly monitoring will occur by both the facility director. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.124(12) | Individual #3's Individual Support Plan (ISP) indicated he/she could receive 30 minutes of unsupervised time at the vocational program and that he/she should be supervised at all times when in the community. His/Her 3/31/17 assessment indicated he/she could be unsupervised for 15 minutes at program and in the community.
-Individual #2's ISP indicates he/she is supervised between 1:2-1:3 staff to individual ratio in the community. His/Her 7/26/17 assessment indicates he/she can be unsupervised for up to 15 minutes at the vocational facility and 8 minutes unsupervised in the community.
-Individual #1's 4/17/17 assessment indicates he/she can be unsupervised for up to 15 minutes at program and his/her ISP indicated he/she can be unsupervised up to 10 minutes at day program. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Each client's record must include the following: content discrepancy in the ISP regarding unsupervised time. The program specialist for individual #3 updated (on 3/9/18) her S.C. of the content discrepancy related to her unsupervised time at day program. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to include accurate and consistent data related to her unsupervised time at day program. The program specialist for individual #2 updated (on 3/9/18) her S.C. of the content discrepancy related to her supervised time in the community and unsupervised time at day program. The program specialist for individual #2 updated (on 3/8/18) her assessment to include accurate and consistent data related to her unsupervised time at day program. The program specialist for individual #1 updated (on 3/9/18) his S.C. on the content discrepancy related to his unsupervised time at day program. The program specialist for individual #1 updated (on 3/8/18) his assessment to include accurate and consistent data related to his unsupervised time in day program.
Program Specialists were trained on 3/6/18 on content discrepancy in the ISP and communicating the discrepancy to the supports coordinator (S.C.).
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(1) | Individual #1's assessment dated 4/17/17 did not include functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | The assessment must include the following: functional strengths, needs and preferences. The program specialist for individual #1 updated (on 3/8/18) his assessment to include his current level of functional strengths, needs and preferences.
Program specialists were trained 3/6/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-2018). |
04/11/2018
| Implemented |
| 2390.151(e)(3)(ii) | Individual #3's assessment dated 3/31/17 did not include current level of communication skills. | The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions. | The assessment must include the following: current level of communication skills. The program specialist for individual #3 updated (3/8/18) her assessment (dated 3/31/17) to include her current level of communication: ability to receive, retain and carry out instructions. The program Specialist emailed the amended assessment on 3/9/18.
Program specialists were trained 3/6/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-2018). |
04/11/2018
| Implemented |
| 2390.151(e)(8) | -- Individual #1's assessment dated 4/17/17 did not include the ability to evacuate. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | The assessment must include the following: The client¿s ability to evacuate in the event of a fire. The program specialist for individual #1 updated (on 3/8/18) his assessment (dated 4/17/17) to include his ability to evacuate in the event of a fire. The program specialist sent the updated assessment on 3/9/18.
Program specialists were trained 3/6/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file review will occur. The facility director will oversee and monitor this process of correction (2017-2018) |
04/11/2018
| Implemented |
| 2390.151(e)(10) | Individual #2 and individual #3's assessment did include a review of their lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The assessment must include: a lifetime medical history. The program specialist for individual #2 updated (on 3/8/2018) her assessment (dated 7/26/17) to include her lifetime medical. These documents were sent to individual #2's S.C. (on 3/9/18). The program specialist for individual #3 updated (on 3/8/18) her assessment dated (3/31/17) to include her lifetime medical. These documents were sent to her S.C. (on 3/9/18).
Program specialists were trained on 3/6/18 on requirement of lifetime medical history.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(13)(i) | Individual #3's assessment dated 3/31/17 did not include progress and growth for 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 assessment must include the following: current level in the following area(s): health. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to reflect updates on individual #3's health. The assessment was sent to her S.C. in order to update her ISP.
Program specialists were trained on 3/6/18 on requirement components of an annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(13(ii) | Individual #2's assessment dated 7/26/17 and Individual #3's assessment dated 3/31/17 did not include progress and growth for motor and communication. | 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 assessment must include the following: progress and current level in the following areas: motor and communication. The program specialist for individual #2 updated (on 3/8/18) her assessment (dated 7/26/17) to include her current level and progress in the area of motor and communication. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to include her current level and progress in the area of motor and communication. l
Program specialists were trained on 3/6/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(13)(iii) | Individual #3's assessment dated 3/31/17 did not include progress and growth for 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 assessment must include the following: progress and current level in the following areas: personal adjustment. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to include her current level and progress in the area of personal adjustment.
Program specialists were trained on 3/6/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(13(iv) | Individual #3's assessment dated 3/31/17 did not include progress and growth for socialization 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: Socialization. | The assessment must include the following: current level and progress in the following areas: socialization. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to include current level and progress in the area of socialization. The amended assessment was forwarded to individual #3's S.C. (on 3/9/18) in order to update her ISP.
Program specialists were trained on 3/6/18 on the required components of an annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(e)(13)(v) | Individual #3's assessment dated 3/31/17 did not include progress and growth for 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 assessment must include the following: current level and progress in the following areas: vocational skills. The program specialist for individual #3 updated (on 3/8/18) her assessment (dated 3/31/17) to include current level and progress in the area of vocational skills. The amended assessment was forwarded to individual #3's S.C. (on 3/8/18) in order to update her ISP.
Program specialists were trained on 3/6/18 on the required components of an annual assessment.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.151(f) | - Individual #2's assessment dated 7/26/17 was not sent to his/her mother or sister. | 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). | The program specialist must provide copies of the assessment to the S.C. and team members at least 30 calendar days prior to the ISP meeting. As per team discussion (on 8/28/17). Individual¿s mother and sister declined to attend team meetings and declined to attend individuals ISP meeting. The S.C. changed the mother and sister status to emergency contact only.
The program specialist was trained on 3/6/18 regarding paperwork requirements for annual assessments.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.153(3) | Individual #2's Individual Support Plan (ISP) outcome earn money' didn't include the method of evaluation. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | The ISP including annual updates and revisions must include the following: the current status in relation to the outcome and the method of evaluation used to determine progress towards the outcome. The program specialist for individual #2 emailed the Supports Coordinator with a request to update the ISP with the appropriate method of evaluation used to determine progress toward her outcome.
Program specialists were trained on 3/6/2018 on ISP and required components.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.153(7)(i) | Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. | 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: Vocational programming. | The ISP including annual updates and revisions must include: an assessment of the client's potential to advance in the following: vocational programming. The program specialist for individual #1 updated (on 3/8/2018) his assessment (in the area of potential to advance in vocational programming. The program specialist sent the updated assessment (on 3/9/2018) to individual #1's S.C. with the request to update the ISP regarding individual #1¿s potential to advance in programing.
Program specialists were trained on 3/6/2018 on assessing a client's potential to advance in vocational programming and to include this in the client's annual assessment in order to update the ISP.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.153(7)(ii) | -- Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive, 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 ISP including annual updates and revisions must include: an assessment of the client's potential to advance in the following: community-integrated and competitive employment. The program specialist for individual #1 updated (on 3/8/2018) his assessment to include his ability to advance in competitive community-integrated employment and forwarded this assessment to individual #1's S.C. in order for updates to be made to the ISP.
Program specialists were trained on 3/6/2018 on ISP and annual assessments required components.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.156(c)(1) | Individuals #1- #3's Individual Support Plan (ISP) reviews did not review the prior three months. For example Individual #3's ISP review dated 2/2/18 was supposed to review 11/1/17 to 2/1/18 but it reviewed October to December. The ISP reviews also did not include the individuals' participation and progress towards their ISP outcomes. | 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 ISP review must include the following: participation and progress towards the ISP outcome. The ISP review was updated to include the following: review of participation and progress toward the ISP outcomes supported by the services provided by the facility licensed under this chapter. The Program Specialist updated (on 3/8/18) Individual # 1's ISP reviews to reflect participation and progress towards his ISP outcome. The Program Specialist updated (on 3/8/18) Individual #1¿s ISP reviews that review the prior three months. The Program Specialist updated (on 3/6/18) Individual # 2's ISP reviews to reflect participation and progress towards her ISP outcome. The Program Specialist updated (on 3/9/18) Individual #2¿s ISP reviews that review the prior three months. The Program Specialist updated (on 3/9/18) Individual # 3's ISP reviews to reflect participation and progress towards his ISP outcome. The Program Specialist updated (on 3/9/2018) Individual #3¿s ISP reviews that review the prior three months.
Program Specialists were trained on 3/6/2018 on ISP reviews and required components.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |
| 2390.156(c)(2) | Individual #2's Individual Support Plan (ISP) review didn't review his/her plan to address his/her social, emotional and environmental needs plan. Individual #3's ISP reviews didn't review his/her community participation. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The ISP review must include the following: a review of each section of the ISP. The ISP review was updated to include the following: review of her plan to address her social, emotional and environmental needs plan for individual #2, and a review of her community participation for individual #3. The Program Specialist for individual #2 updated (3/6/18) her ISP reviews to include her social, emotional, environmental plan. The Program Specialist for individual #3 updated (3/9/18) her ISP reviews to review her community participation.
Program specialists were trained on 3/6/2018 on ISP review and required components.
All program specialists will be retrained on the requirements of individual files and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
04/11/2018
| Implemented |