| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist is not completing the assessment. Through interviews with the program specialists at the agency, it was revealed that the house manager is completing the assessments and the program specialist is signing off on the document. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The Program Specialist will be responsible for coordinating and completing assessments. The Program Specialist will be the author of the assessment in the electronic health record. The Program Specialist has completed a revised assessment for Individual #1 on 6/19/15 and is the author of the document. (Attachment #5, Pg.9). All Program Specialists will be retrained in Reg. 6400.44(b)(1) to ensure that the Program Specialist coordinates and completes assessments. Each individual record will be reviewed by 9/30/15 to ensure that the Program Specialist has coordinated and completed the assessment. |
08/31/2015
| Implemented |
| 6400.163(c) | Individual #1's psychiatric medication review documentation is not accurately reviewing the reason for prescribing the medication. Individual #1 takes Risperdal and Wellbutrin for depression and delusional disorder. The medication reviews indicate her medications are treating anxiety and mood disorder, diagnosis she does not have. The documentation does not address her actual diagnosis of depression and delusional disorder. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there will be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 had a psychiatric medication review on 6/2/15 and an attempt was made to clarify the diagnoses for which she is being treated. The doctor was not willing to provide the information needed, so a follow-up appointment has been scheduled on 7/30/15 to discuss the need for a more cooperative psychiatrist in order to address this concern. All Program Specialists and house supervisors will be retrained in Reg. 6400.163(c) to ensure that there is a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
08/31/2015
| Implemented |
| 6400.181(e)(1) | The assessment for Individual #1 did not include functional strengths, needs, and preferences of the individual. The progress and growth sections in the assessment had a section to address the strength and needs but these sections did not contain the information. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment will include functional strengths, needs and preferences of the individual. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include functional strengths, needs and preferences of the individual. (Attachment #5, Pg.3-7). All Program Specialists will be retrained in Reg. 6400.181(e)(1) to ensure that assessments include functional strengths, needs, and preferences of the individual. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(3)(i) | The assessment for Individual #1 did not contain current level or progress in aquisition of functional skills. The assessment did not contain a section to address this information. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | The assessment will include the individual's current level of performance and progress in the acquisition of functional skills. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include current level of performance and progress in the acquisition of functional skills. (Attachment #5, Pg.3-7). All Program Specialists will be retrained in Reg. 6400.181(e)(3)(i) to ensure that assessments include the current level and progress in acquisition of functional skills. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(6) | The assessment for Individual #1 did not include the individual's ability to safely use or avoid poisonous materials. The assessment had a section to address this however, the information listed didn't address what the regulation is asking for. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment will include the individual's ability to safely use of avoid poisonous materials, when in the presence of poisonous materials. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her ability to safely use of avoid poisonous materials. (Attachment #5, Pg.2). All Program Specialists will be retrained in Reg. 6400.181(6) to ensure that assessments include the individual's ability to safely use or avoid poisonous materials. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(7) | The assessment for Individual #1 did not include her knowledge of heat sources and her ability to sense and move away quickly. The assessment had contradictory information relating to supervision required around heat sources. In one section, the assessment indicated she did not need supervision around heat sources and another section stated she would need supervision around a microwave/oven. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment will include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her knowledge of heat sources and ability to sense and move away quickly. (Attachment #5, Pg.2). All Program Specialists will be retrained in Reg. 6400.181(7) to ensure that assessments include knowledge of the danger of heat sources and ability to sense and move away quickly. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(12) | The assessment for Individual #1 did not include recommendations for specific areas of training, programming and servies. This section of the assessment indicated a need to work on her personal hygiene. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment will include recommendations for specific areas of training, programming and services. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include recommendations for specific areas of training, programming and services. (Attachment #5, Pg.9). All Program Specialists will be retrained in Reg. 6400.181(12) to ensure that assessments include recommendations for specific areas of training, programming and services. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(ii) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in motor and communication skills. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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 will include the individual's progress over the last 365 calendar days and current level in the area of motor and communication skills. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in motor and communication skills. (Attachment #5, Pg.4). All Program Specialists will be retrained in Reg. 6400.181(13)(ii) to ensure that assessments include progress over the last 365 days and current level in motor and communication skills. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(iii) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in 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. | The assessment will include the individual's progress over the last 365 calendar days and current level in activities of residential living. The Program specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in activities of residential living. (Attachment #5, Pg.4). All Program Specialists will be retrained in Reg. 6400.181(13)(iii) to ensure that assessments include progress over the last 365 days and current level in activities of residential living. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(iv) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in personal adjustment. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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 will include the individual's progress over the last 365 calendar days and current level in personal adjustment. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in personal adjustment. (Attachment #5, Pg. 4 and 5). All Program Specialists will be retrained in Reg. 6400.181(13)(iv) to ensure that assessments include progress over the last 365 days and current level in personal adjustment. Each individual record will be reviewed to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(v) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in socialization. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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 will include the individual's progress over the last 365 calendar days and current level in socialization. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in socialization. (Attachment #5, Pg.5). All Program Specialists will be retrained in Reg. 6400.181(13)(v) to ensure that assessments will include current level and progress over the last 365 days in socialization. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in recreation. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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. | The assessment will include the individual's progress over the last 365 calendar days and current level in the area of recreation. The Program Specialist has updated the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in recreation. (Attachment #5, Pg. 5). All Program Specialists will be retrained in Reg. 6400.181(13)(vi) to ensure that assessments include current level and progress over the last 365 days in recreation. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(vii) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in financial independence. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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.
| The assessment will include the individual's progress over the last 365 calendar days and current level in financial independence. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in financial independence. (Attachment #5, Pg5 and 6.). All Program Specialists will be retrained in Reg. 6400.181(13)(vii) to ensure that assessments include current level and progress over the last 365 days in financial independence. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(viii) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in managing personal property. This section is combined with financial independence and does not address her ability to manage her personal property or the progress made over the last year. | 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. | The assessment will include the individual's progress over the last 365 days and current level in managing personal property. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in managing personal property. (Attachment #5, Pg. 5 and 6). All Program Specialists will be retrained in Reg. 6400.181(13)(viii) to ensure that assessments will include current level and progress over the last 365 days in managing personal property. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(13)(ix) | The assessment for Individual #1 did not include her current level and progress over the last 365 days in cummunity integration. The information contained in the current assessment was the same information that was reported in last year's assessment. | 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. | The assessment will include the individual's progress over the last 365 calendar days and current level in community integration. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her current level and progress over the last 365 days in community integration. (Attachment #5, Pg.6). All Program Specialists will be retrained in Reg. 6400.181(13)(ix) to ensure that assessments include current level and progress over the last 365 days in community integration. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.181(e)(14) | The assessment for Individual #1 did not include her knowledge of water safety. | 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. | The assessment will include the individual's progress over the last 365 calendar days and current level in knowledge of water safety and ability to swim. The Program Specialist has revised the assessment for Individual #1 on 6/19/15 to include her knowledge of water safety. (Attachment #5, Pg.3). All Program Specialists will be retrained in Reg. 6400.181(14) to ensure that assessments include progress over the last 365 days and current level in knowledge of water safety and ability to swim. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. |
08/31/2015
| Implemented |
| 6400.186(c)(2) | Individual #1 is able to remain at home alone for up to 2 hours. Her ISP reviews aren't reviewing her supervision needs. The ISP reviews should be reviewing the amount of time she is able to remain alone; if she is using this time and how often, and if she can work on increasing this time. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The ISP review will include a review of each section of the ISP specific to the residential home. The Program Specialist has completed an ISP review dated 6/1/15 to include a review of Individual #1's supervision needs, including the amount of time she is able to remain alone, if she is using this time and how often and if she can work on increasing this time. (Attachment #3, Pg.2). All Program Specialists will be retrained in Reg. 6400.186(c)(2) to ensure that ISP reviews include a review of each section of the ISP specific to the residential home. Each individual record will be reviewed by 9/30/15 to ensure that ISP reviews include a review of each section of the ISP specific to the residential home. |
08/31/2015
| Implemented |
| 6400.186(e) | The program specialist did not notify all plan team memebers on the option to decline the ISP review documentation. The day program she attends was not given the option to decline. Any new plan team members need to be notified of their right to decline the review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist will notify the plan team members of the option to decline the ISP review documentation. The Program Specialist notified the day program for Individual #1 of the option to decline the ISP review documentation on 5/15/15. (Attachment #4). All Program Specialists will be retrained in Reg. 6400.186(e) to ensure that all plan team members are notified of the option to decline the ISP review documentation. Each individual record will be reviewed by 9/30/15 to ensure that the Program Specialist has notified all plan team members of their option to decline the ISP review documentation. |
08/31/2015
| Implemented |
| 6400.213(11) | Individual #1's record contains content disrecepancy regarding her diet. All documents indicate she is to follow a 1000 calorie, ADA diet. There is a document hanging on the refrigerator in her home that indicates to staff that she is to follow a low fat, low fiber diet. This information is not contained anywhere in her record. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Each individual's record will include consistent content in the ISP and all other documents in the record. For Individual #1, the ISP did state that she is prescribed to follow a low fiber, low fat diet. (Attachment #1). Individual # 1's physical examination has been updated to include this information. (Attachment #2). All Program Specialists will be retrained in Reg. 6400.213(11) to ensure that each individual's record contains consistent content in the ISP and all other documents in the record. Each individual record will be reviewed by 9/30/15 to ensure that the content is consistent. |
08/31/2015
| Implemented |