| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(4) | Individual #1 Assessment does not address the individuals level of supervision. | The assessment must include the following information: The individual's need for supervision.
| On 7/24/19 the Program Specialist completed an addendum to the annual assessment to address the area of "the -individual's need for supervision."
On 7/29/19 the Residential Associate Director completed training with Program Specialist staff. This training addressed completion of annual assessment. Documentation of training will be kept in staff files.
A 100% review of annual assessments was completed by Program Specialist staff on 11/27/19. Any issues noted during this review were corrected using an addendum to the annual assessment.
For a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of residential consumers to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
11/27/2019
| Implemented |
| 6400.181(e)(5) | Individual #1 Assessment does not address the individuals ability to self-administer medication. | The assessment must include the following information: The individual's ability to self-administer medications. | On 11/18/19 the Program Specialist completed an addendum to the annual assessment to address the area of -individual's ability to self-administer medications'.
In advance of this addendum the Program Specialist obtained a separate assessment related to self-administration of medications created by the team on 8/5/18.
On 7/29/19 the Residential Associate Director completed training with Program Specialist staff. This training addressed completion of annual assessment. Documentation of training will be kept in staff files.
A 100% review of annual assessments was completed by Program Specialist staff on 11/27/19. Any issues noted during this review were corrected using an addendum to the annual assessment.
For a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of residential consumers to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
11/27/2019
| Implemented |
| 6400.181(e)(9) | Individual #1 Annual Assessment does not address the Individuals disability and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | On 7/24/19 the Program Specialist completed an addendum was added to the annual assessment to address the area of -individual's disability and medical limitations.
On 7/29/19 the Residential Associate Director completed training with Program Specialist staff. This training addressed completion of annual assessment. Documentation of training will be kept in staff files.
A 100% review of annual assessments was completed by Program Specialist staff prior to 11/27/19. Any issues noted during this review were corrected using an addendum to the annual assessment.
For a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of residential consumers to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
11/27/2019
| Implemented |