| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | Program Specialist #1 had a physical examination completed 3/13/2020 and then again 6/17/2022. Direct Service Worker #2 had a physical examination completed 2/26/2018 and then again 8/17/2020. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The physical for PS #1 was completed on 6/17/22
And for DSP #2 was completed 8/17/20 and most recently on 6/17/2022 |
08/08/2022
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #2 had a tuberculin skin test completed 2/28/2018 and then again 8/20/2020. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | DSP worker 2 received her TB on 6/29/22 |
08/08/2022
| Implemented |
| 2380.181(a) | Individual #3 had an assessment completed 1/07/2021 and then again 4/27/2022. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | The program specialist will make a spreadsheet to address the citations in regards to the late annual physical, assessments, required medical appointments, current ISP date. The spreadsheet will posted at the site. |
08/08/2022
| Implemented |
| 2380.181(e)(4) | Individual #2's assessment completed 7/21/2021 states the individual is unable to be in the facility without supervision and requires supervision in the community at all times. Individual #2's individual support plan, last updated 6/21/2022, states she needs physical supervision when in the community and that she uses a wheeled walker when ambulating in the community and staff support her by staying in arm's length away form her in case she starts to fall down. Individual #3's assessment completed 4/27/2022 states the individual is unable to be in the facility or community without supervision. Individual #3's individual support plan, last updated 6/21/2022 states he attends program from 8AM to 2PM, Monday through Friday, and the staff ratio 1:7 to 1:10 in the facility and1:2 or 1:3 in the community. Individual #4's assessment completed 12/28/2021 states the individual is unable to be in the facility or community without supervision. Individual #4's individual support plan, last updated 5/31/2022, states she needs to remain within eyesight at all times while in the community. | The assessment must include the following information: The individual¿s need for supervision. | The assessment which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also the expanded text boxes will be made required fields for completion. |
08/08/2022
| Implemented |
| 2380.181(e)(5) | Individual #2's assessment completed 7/21/2021 states the individual does not take medications at program. Individual #2's individual support plan, last updated 6/21/2022, states she does not know times, does, targets, or names of medication and that staff are to administer the medications to her and document on the medication administration record. Individual #3's assessment completed 4/27/2022 states the individual's ability to self administer medications is not applicable. Individual #3's individual support plan, last updated 6/21/2022, states he does not self-medicate and staff assist with medication administration in which he takes his medications whole with water, with verbal prompts and partial physical assistance. Individual #4's assessment completed 12/28/2021 states the individual's ability to self-administer medications is not applicable. Individual #4's individual support plan, last updated 5/31/2022, states the individual does self-medicate and it also states she needs some assistance with medication administration, taking the correct doses at the correct time each day. It states the individual can take medications independently with a verbal reminder, but she needs assistance with inhalants. | The assessment must include the following information: The individual¿s ability to self-administer medications. | The assessment which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also the expanded text boxes will be made required fields for completion. |
08/08/2022
| Implemented |
| 2380.181(e)(6) | Individual #2's assessment completed 7/21/2021 documents the individual being able to avoid poisonous materials as not applicable and states all poisonous materials are locked away. Individual #2's individual support plan, last updated 6/21/2022, states she would not ingest poisonous substances and is independent with recognizing the danger of ingesting poisonous materials including cleaning supplies and personal hygiene products. | 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 which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also the expanded text boxes will be made required fields for completion. |
08/08/2022
| Implemented |
| 2380.181(e)(14) | Individual #2's assessment completed 7/21/2021 states the individuals ability to swim is not applicable. Individual #2's individual support plan, last updated 6/21/2022, states the individual does not know how to swim and does not go swimming. It also states she requires verbal prompts to stay away from the edges of bodies of water such as pools, ponds, rivers, lakes, and oceans, and that if she did get close staff would physically support her by ensuring she does not fall in and redirect her to move away from the water. Individual #3's assessment completed 4/27/2022 states the states the individuals ability to swim is not applicable. Individual #3's individual support plan, last updated 6/21/2022, states he needs someone within arm's length while in a swimming pool to maintain his safety with partial physical assistance and that he is not aware of water depth so a lifeguard or trained staff should be on site, and he should only swim in shallow water. Individual #4's assessment completed 12/28/2021 states the individual's ability to swim is not applicable. Individual #4's individual support plan, last updated 5/31/2022, states she cannot swim and that she likes to go into the shallow end of the swimming pool and needs to remain within sight of caregiver and she would not enter into a pool or other body of water unattended or unsupervised. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | The assessment which is completed in our electronic medical record will be revised so that N/A will not available as a selection for areas that are required to be assessed. Also the expanded text boxes will be made required fields for completion. |
08/08/2022
| Implemented |
| 2380.39(c)(6) | Program Specialist #1, date of hire 8/01/2014, has no documentation of having training in implementation of the individuals plans. Direct Service Worker #2, date of hire 6/25/1994, has no documentation of having training in implementation of the individuals plans. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | An updated signature page for staff to sign off on annually or when the plan changes. It includes the below statement on the signature page.
My Signature indicates that I have reviewed the attached documents and I agree to implement the plans written. When reviewing the ISP, I reviewed person-specific information from the most current ISP based upon the assessment as well as the current SEEP (if applicable) to become knowledgeable about the person including, but not limited to the following areas:
¿ The needs of the person and practices necessary to assure the person¿s health, safety, and welfare including the person¿s mode of communication
¿ What is important to the person including preferred activities, foods and relationships
¿ Safe eating/feeding procedures
¿ Respiratory maintenance and treatments
¿
¿ Positioning and transferring procedures
¿ Skin Integrity protocols
¿ Individual-specific emergency procedures
¿ The safe and appropriate use of trauma-informed behavior supports
¿ Understanding of age-related factors such as interests, preferred activities, and stamina |
08/08/2022
| Implemented |
| 2380.181(f) | Individual #1's assessment completed 5/24/2022, was sent to the plan team members 5/20/2022 prior to it being signed by Program Specialist #1. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The program specialist will make a spreadsheet to address the citations in regards to the late annual physical, assessments, required medical appointments, current ISP date. The spreadsheet will posted at the site. |
08/08/2022
| Implemented |