| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff #2's physcial was on 6/20/13 and then again on 9/2/15. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | AVS is unable to correct this violation.
To assure there is no recurrence of this event, the Administrative Assistant met with the Administrator to complete a training on Physical and TB test notifications (Staff Attendance Sheet with training Attachment #9) The Administrative Assistant created a tracking sheet for all staff physical and TB test due dates starting in December 2015 (Tracking Form Attachment # 10). The physicals and TB tests that were due in December 2015 were completed (Physicals and TB Tests Attachment #11). This will be monitored by the Administer with monthly meeting with the Administrative Assistant.
|
12/21/2015
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in 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. | To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment ( Progress and Growth Attachment #19). |
12/21/2015
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in 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. | To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #19). |
12/31/2015
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in 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.
| To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #19). |
12/31/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in 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. | To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #19). |
12/31/2015
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in 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. | To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding the progress and growth comments in the assessment (Staff Attendance Sheet Attachment #18). Completed assessments will be reviewed by the Social Service Supervisor for thoroughness and accuracy in progress and growth. If concerns arise during the review, the Program Specialist will be notified and appropriate revisions will be made to the document. The Program Specialist completed a revision to the progress and growth section of the assessment (Attachment #19). |
12/31/2015
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews did not review the fall reduction plan and on 7/3/15, 1/30/15, and 11/21/14 did not review the dental hygiene plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | To assure there is no recurrence of this event, the Program Specialist will be retrained by the Social Services Supervisor regarding review of all parts of the ISP. This included the importance of reviewing all aspects of the individual¿s ISP and commenting in the 3 month review (Staff Attendance Sheet Attachment # 20). 3 month reviews will be reviewed by the Social Services Supervisor starting on 12/3/2015 through 3/3/2016. If concerns arise during the review, the Program Specialist will be notified by the Social Services Supervisor and the concerns will be addressed. |
03/03/2016
| Implemented |
| 6400.187 | Individual #1's ISP meeting was held on 8/28/15 and no approval letter was sent as of the date of the renewal. | A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings.
| AVS is unable to correct this violation.
To assure there is no recurrence of this event, the Program Specialist; who does not act as the plan lead, will be trained by the Social Service Supervisor to document all attempts made to the plan lead; the Supports Coordinator, to obtain a copy of the ISP within 30 days of the ISP planning meeting (Staff Attendance Sheet with training Attachment # 22). This will include the ISP, annual updates, and revision meetings. |
10/19/2015
| Implemented |