| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(a) |
Individual #1 was admitted 4-11-13 and the rights were not reviewed until 4-18-13.
| (a) Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter.
| The Manager of Residential Services has retrained the Program Specialist to ensure that all new admissions are informed of their rights upon admission and annually thereafter. Being informed of their rights has been incorporated into an admission checklist that will be followed by the Program Specialist and submitted to the Manager of Residential Services after completion. The Manager of Residential Programs will also follow up with a phone call to the home the day of admission to ensure that the rights have been reviewed with the individual. The Manager of Residential Programs will document the follow up call on the Admission checklist and forward the checklist to the Director for a period of one year. Training was completed on 10/24/13. |
10/24/2013
| Implemented |
| 6400.113(a) | Individual # 1 who was admitted 4-11-13 did not receive fire safety training until 4-18-13. | (a) An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home.
| The Manager of Residential Services has retrained the Program Specialist to ensure that all new admissions receive fire safety training on the day they are admitted. Receiving fire safety training has been incorporated into an admission checklist that will be followed by the Program Specialist and submitted to the Manager of Residential Services after completion. The Manager of Residential Programs will also follow up with a phone call to the home the day of admission to ensure that the fire safety training was completed. The Manager of Residential Programs will document the follow up call on the Admission checklist and forward the checklist to the Director. Training was completed on 10/24/13. |
10/24/2013
| Implemented |
| 6400.181(e)(10) | Individual #1¿s assessment dated 5-29-13 did not include a lifetime medical history. | (10) A lifetime medical history.
| The Manager of Nursing has retrained the Nurses to ensure that a Lifetime medical history is included in the individuals assessment and that when an individual is admitted the nurse will ensure that all pertinent and updated information is obtained from the family or previous provider to include in the lifetime medical history. If all information is not able to be obtained the nurse will document this and their attempts to obtain the information on the assessment. The Manager of Nursing will review all lifetime medical history reports prior to submission to the record and sign off on the report indicating their approval. Training was completed on 10/24/13. |
10/24/2013
| Implemented |
| 6400.186(c)(4)(ii) | Individual #1 who was admitted 4-11-13 ISP did not include current outcomes and there was no documentation from the Program Specialist to the Supports Coordinator informing them of the omission. | (ii) The addition of an outcome or service to support the achievement of an outcome.
| Individual #1 who was admitted to the Residential Community Home at 501 Pinewood Rd did not have supporting documentation that the Program Specialist made recommendations to the Supports Coordinator regarding the addition of outcomes. The Program Specialist was re-trained on 12-3-2013 to ensure that when an individual is admitted to a Residential Community Home, supporting documentation will be provided to the Supports Coordinator electronically by email, fax, and/or mail and forwarded to the Manager of Residential Services electronically by email and/or physical copy. Supporting documentation of recommendations of additional outcomes will be kept in the Residential Program Books under the correspondence section. A copy of this correspondence will be kept on file electronically and physically in the Individual¿s records. If a recommendation of additional outcome is outstanding for over 30 days, the Program Specialist will complete a Content Discrepancy, according to 6400.44(7)- Program Specialist will report content discrepancy to the Support Coordinator, as applicable, and a content discrepancy will be submitted to the Director. A record of this correspondence will be kept electronically and in the individual¿s physical file. The Program Specialist will continue to review and monitor the Individual Support Plan quarterly and submit Quarterly Progress Reports that include the recommendations of additional outcomes and the start dates to the Manager of Residential Services, Support Coordination, and team members. |
12/03/2013
| Implemented |