| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was a dresser in individual #3's bedroom that was missing knobs. There was a dresser in individual #3's bedroom that was missing knobs. Individual #4's bedroom had a broken heater cover. | Floors, walls, ceilings and other surfaces shall be in good repair. | A repair request was submitted to Bancroft¿s Facilities department to replace the missing knobs on individual #3¿s dresser as well as to repair the broken heater cover in individual #4¿s bedroom. These repairs were completed. |
04/03/2017
| Implemented |
| 6400.68(b) | The water temperature in the home was tested and found to be 129 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | A repair request was submitted to Bancroft¿s Facilities department to adjust the temperature of the water in the home. This repair request was completed. Staff will continue to take water temperatures on a daily basis. |
04/03/2017
| Implemented |
| 6400.71 | There were no emergency numbers listed by the phone in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency numbers including the nearest hospital, police department, fire department, ambulance and poison control center have been posted next to the phone in the kitchen. Please see Attachment number 13 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.111(f) | There was a fire extinguisher in the second floor hallway that did not have an inspection tag. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | An inspection tag has been attached to the fire extinguisher with the annual inspection date. |
04/03/2017
| Implemented |
| 6400.181(d) | Individual #3's annual assessment dated 10/20/16 was not signed by the program specialist. | The program specialist shall sign and date the assessment. | Individual #3¿s annual assessment has been updated to include the Program Manager/Specialist¿s signature. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(8) | Individual #3's annual assessment dated 10/20/16 did not include the ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, the ability to evacuate in the event of a fire. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth in the area of 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(iv) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(vii) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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.
| Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(viii) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth 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. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(14) | Individual #'s annual assessment dated 10/20/16 did not include progress and growth in the area of water safety and ability to swim | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #3¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 12 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.183(3) | Individual #3's annaul ISP dated 2/15/16 did not have a method to evaluate the progress towards outcomes. | The ISP, including annual updates and revisions under § 6400.186 (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 Program Manager/Specialist is responsible to update the Progress Note each month. There is a specific section on each Monthly Progress Note designated to explaining the method of evaluating progress towards the outcome goals. As of 2/17, Program Managers/Specialists have been trained on properly completing this Monthly Progress Note. Please see Attachment number 8 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.213(1)(i) | Individual #3's record did not list their religious affiliation | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #3¿s record has been updated to include her religious affiliation. |
04/03/2017
| Implemented |