| 6400.181(a) | Individual #1 had an annual assessment completed on 05/25/23, and then again on 07/24/24. This exceeds the annual requirement. [Repeat Violation 02/27/24 et. al.]. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | In July of 2024, a review of individual assessments was done. Due to Agency Turnover, it was identified that there was a lapse in compliance for this individual relating to the completion dates of the annual assessments. The agency implemented a tracking system on 1/8/24 however due to agency turnover the relevant information was not correctly entered in the tracking system. Beginning on 7/1/24 the Agency conducted an audit of the assessments for all individuals. Upon discovery that the assessment for individual 1 had not been completed the Agency reviewed and revised the assessment on 7/24/24. Beginning on 3/18/25 the agency will make note any identified lapses in compliance and report all violations to the state licensing agents as required prior to licensing. The Program Specialists and Program Compliance Specialist will report all violations to the COO. |
03/18/2025
| Implemented |
| 6400.181(f) | Individual #1's annual assessment was sent to the Supports Coordinator and Plan Team on 06/03/24 for an annual ISP meeting conducted on 07/02/24. This is not at least 30 calendar days prior to the individual plan meeting. [Repeat Violation 02/27/24 et. al.]. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The agency implemented a tracking system on 1/8/24 however due to agency turnover the relevant information was not correctly entered in the tracking system. Upon being notified of the violation by the state inspector on 2/26/2025, The agency updated its internal policy. Effective 3/18/25. If the individual plan meeting has been scheduled in sufficient time, the PS will send the annual assessment to the Supports Coordinator and Plan team no less than 35 days prior to the individual plan meeting. If the plan meeting has been scheduled for less than 35 days from the date the agency received notice of the plan meeting, the PS will send the assessment to the plan day within one day of receipt of the notice. |
03/18/2025
| Implemented |