| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | There was an bottle of a blue liquid later identified by the program specialist as windshield washer fluid in the hallway closet near the laundry area that was not locked. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All poisonous materials are locked in a supply cabinet with no access to individuals. We are not keeping any automotive supplies on site. See photo of locked supply cabinet. [The bottle of a blue liquid was removed at 10:30 AM on 8/10/16 by the program specialist. Within 30 days of receipt of the plan of correction, the Director and/or site supervisor shall develop and implement policies and procedures to ensure all poisonous materials are locked or made inaccessible to individual when not in use. Within 60 days of receipt of plan of correction and upon hire all staff person shall be trained in aforementioned policies and procedures. Documentation of policies and procedures and trainings shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.53(b) | The bottle of a blue liquid later identified by the program specialist as windshield washer fluid in the hallway closet near the laundry area was unlabeled. | Poisonous materials shall be stored in their original, labeled containers. | All poisonous materials shall be stored in their original labeled containers under lock and key supply cabinet. See photo of our supply cabinet.[Within 30 days of receipt of the plan of correction, the Director and/or site supervisor shall develop and implement policies and procedures to ensure all poisonous materials are locked or made inaccessible to individual when not in use. Within 60 days of receipt of plan of correction and upon hire all staff person shall be trained in aforementioned policies and procedures. Documentation of policies and procedures and trainings shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.113(a) | A physical examination for Direct Staff Worker #1 hired on 11/4/1989 could not be located. | 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. | Summation letter of Direct Staff Worker #1 was obtained from Concentra, our employee health provider and letter is submitted. The summation letter verifies the physical was obtained within the specified parameters. [Immediately and upon completion, the Director or designated management staff person shall review all staff person's current physical examination to ensure completion and entered into the staff person record. Within 30 days of receipt of the plan of correction the Director shall develop and implement policies and procedures to ensure all staff persons have physical examination completed and documentation is maintained in the employee's record to include a tracking system and record/file review. Within 60 days of receipt of the plan of correction, all staff person responsible for implementing the aforementioned policies and procedures to ensure staff persons have physical examinations completed as required shall be trained in the aforementioned policies and procedures by the Director. Documentation of trainings, reviews, policies and procedures including the tracking system shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(1) | The assessment completed on 2/29/16 for Individual #1 did not include functional strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | New assessment for approval and signatures to address this issue was completed in My Avatar our new electronic record. New assessment sent and Critical Review form completed and sent to team. [Individual #1 had an assessment completed on 10/11/6 to include functional strengths, needs and preferences of the individual. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessment to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(2) | The assessment completed on 2/29/16 for Individual #1 did not include interests of the individual. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | New assessment for approval and signatures to address this issue was completed in My Avatar our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include interests of the individual. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(3)(i) | The assessment completed on 2/29/16 for Individual #1 did not assess the individual's current level of performance and program in the acquisition of functional skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Acquisition of functional skills. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team..[Individual #1 had an assessment completed on 10/11/6 to include individual's current level of performance and program in the acquisition of functional skills. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(3)(ii) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's current level of performance and progress in communication. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team..[Individual #1 had an assessment completed on 10/11/6 to include the individual's current level of performance and progress in communication. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(3)(iii) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's current level of performance and progress in personal adjustment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's current level of performance and progress in personal adjustment. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(3)(iv) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's current level of performance and progress in personal needs with or without assistance from others. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team..[Individual #1 had an assessment completed on 10/11/6 to include the individual's current level of performance and progress in personal needs with or without assistance from others. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(5) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's ability to self-administer medications. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(6) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's ability to safely use or avoid poisonous materials. | 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. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's ability to safely use or avoid poisonous materials. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(7) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources. | 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. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(8) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's ability to evacuate in the event of a fire. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(12) | The assessment completed on 2/29/16 for Individual #1 did not include recommendations for specific areas of training, vocational programs and competitive community integrated employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(13)(i) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's current level in health. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's current level in health. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(13)(ii) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's progress and current level in motor and communication skills. | 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. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include individual's progress and current level in motor and communication skills. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(13)(iii) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's current level in personal adjustment. | 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. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's current level in personal adjustment. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |
| 2380.181(e)(14) | The assessment completed on 2/29/16 for Individual #1 did not include the individual's knowledge of water safety and the ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | New assessment for approval and signatures to address this issue was completed in My Avatar ,our new electronic record. New assessment sent and Critical Review form completed and sent to team.[Individual #1 had an assessment completed on 10/11/6 to include the individual's knowledge of water safety and the ability to swim. Within the 60 days of receipt of the plan of correction, the program specialist(s) shall review all individuals' current assessments to ensure all required information is included and will update as needed with the missing information and provide to plan team members as required and maintain documentation of correspondence. At least quarterly for 1 year, the Director shall review assessments completed within that quarter to ensure the program specialist completed assessments with all required information. Documentation updates to assessments and of reviews shall be kept. (AS 10/20/16)] |
09/27/2016
| Implemented |