| 2380.182(c) | Individual #1's Individual Support Plan, last updated on 2/27/25, was not revised to reflect their current needs as based on their current assessment, completed on 11/27/24, in the following health and safety skill domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan explained that they are able to sense and quickly move away from such heat sources with independence. However, Individual #1's assessment indicated they cannot sense and quickly move away from these types of heat
sources on their own; and regarding supervision, Individual #1's Individual Support Plan explained that they require a 1:4 to 1:6 (staff-to-individual ratio) at the facility, while in the community, Individual #1 needs constant supervision with a 1:3 (staff-to-individual ratio), including intensive supervision when crossing streets. In contrast, Individual #1's assessment informed that they can be left unsupervised for brief periods of times at the facility and that they require minimal assistance when using the restroom. In the community, Individual #1's assessment stated only that they cannot be left unsupervised. Individual #2's Individual Support Plan, last updated on 3/7/25, was not revised to reflect their current needs as based on their current assessment, completed on 5/31/24, in the following health and safety skill domains: regarding poisonous materials, Individual #2's Individual Support Plan explained that they are able to recognize poisons and chemicals but require visual supervision around them. However, Individual #2's assessment indicated that they are able to recognize, avoid, or use poisonous materials with independence; regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #2's Individual Support Plan informed that they require visual supervision to sense and quickly move away from such heat sources, while their assessment indicated that they are able to sense and quickly move away from dangerous heat sources with independence; and regarding supervision, Individual #2's Individual Support Plan explained that they require a 1:2 to 1:3 (staff-to-individual ratio) at the facility, while in the community, Individual #2 needs a 1:2 to 1:3 (staff-to-individual ratio) with constant visual supervision and requires staff to be within arm's length near traffic. In contrast, Individual #2's assessment informed that they can be left unsupervised for brief periods of times at the facility. In the community, Individual #2's assessment indicated that they require verbal and gestural prompting to use public restrooms with constant supervision needed in social interactions with community members, in traffic, and in making purchases. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Violation: 2380.182 (c)
PLAN OF CORRECTION follows: (All components of the POC were completed by 4/3/25 unless otherwise stated.)
Individual #1's Individual Support Plan, last updated on 2/27/25, was not revised to reflect their current needs as based on their current assessment, completed on 11/27/24, in the following health and safety skill domains:
Regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Individual Support Plan explained that they are able to sense and quickly move away from such heat sources with independence. However, Individual #1's assessment indicated they cannot sense and quickly move away from these types of heat sources on their own.
Individual #1¿s assessment part B was incorrectly marked to indicate that he could NOT independently recognize heat sources and pull away or remove body part from heat source. This information contained within the ISP was confirmed for accuracy with his mother and the assessment part B was corrected. (See attachment A)
Regarding supervision, Individual #1's Individual Support Plan explained that they require a 1:4 to 1:6 (staff-to-individual ratio) at the facility, while in the community, Individual #1 needs constant supervision with a 1:3 (staff-to-individual ratio), including intensive supervision when crossing streets. In contrast, Individual #1's assessment informed that they can be left unsupervised for brief periods of times at the facility and that they require minimal assistance when using the restroom. In the community, Individual #1's assessment stated only that they cannot be left unsupervised.
Individual #1¿s Assessment Part A was updated with following detailed narrative to update supervision needs to align with what was confirmed to be accurate within the ISP:
¿Steven¿s level of supervision in the facility is within ear shot. He is able to be in rooms by himself with staff in the building within adequate hearing distance. He can utilize the restroom independently however, he has a goal to ensure that he washes his hands afterword. (see goal for additional detail) Steven¿s ISP states that he has a tendency to run when in the community. Although this has never been observed by CPS staff, Steven is not to be left unsupervised in the community. He requires constant visual supervision in the community and within arms reach anytime he is near traffic around animals. Steven can utilize the restroom independently while in the community with staff waiting outside the door.¿
Additionally, the assessment part B checklist was revised to remove both sections that reference ability to be left alone for less than 10 seconds/more than 10 seconds as this lacks adequate information.
Due to the number of discrepancies identified between what has been assessed in the CPS environment and what has been reported by mom, a team meeting has been requested to ensure accuracy of the following sections of the ISP and continuity between the ISP and assessment. Like and Admire, Traffic, and Supervision Care Needs. These sections were discussed at his last ISP meeting but there seems to continue to be some confusion as to what is accurate. This meeting has been scheduled for April 10th , 2025 at 10:00 AM.
During this meeting it will also be requested that the SC remove the ratios from the ¿description¿ section of the Supervision Care Needs section and replace with the descriptive narrative from the assessment. Finally, it will be requested that the SC correct the staffing ratio and update with 1:2/3 in Community under the Staffing Ratio section of the ISP to remove the 1:4/6 in facility as this ratio is not accurate.
Individual #2's Individual Support Plan, last updated on 3/7/25, was not revised to reflect their current needs as based on their current assessment, completed on 5/31/24, in the following health and safety skill domains:
Regarding poisonous materials, Individual #2's Individual Support Plan explained that they are able to recognize poisons and chemicals but require visual supervision around them. However, Individual #2's assessment indicated that they are able to recognize, avoid, or use poisonous materials with independence.
Individual #2¿s assessment part B check list was updated with the following info from the ISP which was confirmed to be accurate: (See attachment B)
Regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #2's Individual Support Plan informed that they require visual supervision to sense and quickly move away from such heat sources, while their assessment indicated that they are able to sense and quickly move away from dangerous heat sources with independence.
The ISP information was confirmed to be accurate. The assessment part B check list was updated to include that ¿mom reports she knows not to touch heat sources¿ and that she ¿requires visual supervision¿ (See attachment B)
Regarding supervision, Individual #2's Individual Support Plan explained that they require a 1:2 to 1:3 (staff-to-individual ratio) at the facility, while in the community, Individual #2 needs a 1:2 to 1:3 (staff-to-individual ratio) with constant visual supervision and requires staff to be within arm's length near traffic. In contrast, Individual #2's assessment informed that they can be left unsupervised for brief periods of times at the facility. In the community, Individual #2's assessment indicated that they require verbal and gestural prompting to use public restrooms with constant supervision needed in social interactions with community members, in traffic, and in making purchases.
The assessment part A was updated with the following narrative:
Haley can be left alone within the facility provided staff are within earshot and can hear her. She requires line of sight supervision in the community and within arms length around traffic. She requires verbal prompting in the restroom from staff. This aligns with the wording in the ISP.
Additionally, the assessment part B checklist was revised to remove both sections that reference ability to be left alone for less than 10 seconds/more than 10 seconds as this lacks adequate information.
RESPONSIBLE PARTY: Jason McIntosh, Program Specialist |
04/03/2025
| Implemented |