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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 is 32 years old and has a diagnosis of autism, bipolar disorder, impulse control disorder, and seizure disorder. Individual #1 is mostly nonverbal, communicating via spelling out words or writing words down. Individual #1 has a supervision level of 2:1, with one staff in line of sight at all times and the second staff on the same floor as the individual during awake hours and asleep during sleeping hours. Additionally, staff are to be within line of sight with constant supervision while bathing due to Individual #1's history of seizures. Individual #1 also needs hand over hand assistance with bathing according to their Individual Support Plan and 6/16/23 assessment.
Staff person #12 noted in daily notes and body checks on 9/4/23 between 4pm and 815pm that there was "discoloration of older injuries to [Individual #1's] left arm and chest." This prompted a Station MD Telehealth appointment to address the significant bruising on their left arm, chest, and back that had an unknown origin and initiated a certified investigation. During this investigation, staff person #5 admitted that on 9/1/23, they noted some bruises on Individual #1's left arm when completing a body check. Staff person #4 admitted that on the morning of 9/3/23, they noticed bruises and scars all over Individual #1's body with yellow marks and that Individual #1 was having trouble walking. Staff person #9 admitted that they noticed marks on the morning of 9/3/23.
This serious injury was noticed by staff multiple times, as early as 9/1/23, but remained unreported until 9/5/23 and medical attention was not sought until 9/5/23 when Individual #1 had a Station MD Telehealth appointment for the injury. A certified investigation confirmed that staff person #5 had physically abused Individual #1 on 8/31/23, causing the extensive bruising. This investigation was not started until 9/6/23, and the target staff was not identified and separated from the individual until that same date, allowing the potential for further serious injury to occur to Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | On 9/26/23 the target in this incident was terminated from employment with CSG.
The Skyline Drive team met with the Director of IDD Services on 10/25/23 to review and discuss the incident that occurred with individual #1 and to discuss strategies for improvements and prevention of further abuse incidents. See sign in sheet.
All Staff were retrained on 10/25/23 by the Program Specialist on the Individual Support Plan, assessment, and the expectations for maintaining all required safety and supervision levels, protocols and procedures for the individual. This included training on the required level or staff support for individual #1 and emphasized the need for staff to be on the same floor as the individual during awake hours and asleep during sleeping hours, protocols and procedures for the individual. See sign in sheet.
All staff were retrained on the Behavior Support Plan by the Behavior Specialist on 10/25/23. See Sign in sheet.
The Skyline Drive team was retrained by the Program Director on CSG's Abuse and Neglect Policy, and the CSG IDD Abuse and Neglect Form on 10/25/23. See sign in sheet.
The ISP indicates that staff supporting individual #1 will be trained in Autism and Aggressive behaviors. The training that is actually required is Introduction to Autism Spectrum Disorder and Providing Support for Challenging Behavior. The Program Specialist emailed the SC on 10/31/23 to request a change in wording in the ISP related to the required training for staff. See email. |
11/02/2023
| Implemented |
| 6400.18(a)(9) | Unexplained injuries were noted by staff as early as 9/1/23, however, these unexplained injuries, which were later tied to physical abuse, were not reported in the department's incident management system until 9/6/23 at 8:45am. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| On 9/5/23, DSP staff reported bruising and injuries to Individual #1. An EIM incident was filed for Unexplained injuries. Individual #1's family was notified of the incident on 9/5/23. A Certified Investigation was started on 9/6/23 to look into the Unexplained Injuries on Individual #1. When the Investigator was completing witness statements with DSPs, an allegation was made by DSPs that the bruising may have been caused by a specific staff member and an allegation of Abuse was made. The target of the abuse allegation was suspended immediately on 9/6/23.The EIM incident of Unexplained Injury was updated to an Abuse Incident and Abuse Investigation. The 9/1/23 documentation on individual#1's body chart was not discovered until after the investigation started on 9/6/23.
The Program Director met with staff on 10/25/23 and reiterated the requirement that all staff must report all bruises, injuries, or any other concerns to a supervisor or on call immediately even if they have documented them. All staff were retrained on 10/25/23 by the Program Director on CSG's Abuse and Neglect Policy, Incident Reporting and Management for IDD Services and the Incident Management Bulletin. See sign in sheet.
The Program Director retrained the point persons on 11/1/23 on CSG's Incident Reporting and Management for IDD Services and on the ODP Incident Management Bulletin with a specific focus on the requirement to notify family within the required time frame. The Program Director stressed the importance of family notifications. |
11/02/2023
| Implemented |
| 6400.18(c) | Individual #1's unexplained injuries were noted by staff as early as 9/1/23, however, Individual #1's family was not notified until 9/5/23. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | On 9/5/23, DSP staff reported bruising and injuries to Individual #1. An EIM incident was filed for Unexplained injuries. Individual #1's family was notified of the incident on 9/5/23. A Certified Investigation was started on 9/6/23 to look into the Unexplained Injuries on Individual #1. When the Investigator was completing witness statements with DSP's, an allegation was made by DSPs that the bruising may have been caused by a specific staff member and an allegation of Abuse was made. The target of the abuse allegation was suspended immediately on 9/6/23.The EIM incident of Unexplained Injury was updated to an Abuse Incident and Abuse Investigation. The 9/1/23 documentation on individual#1's body chart was not discovered until after the investigation started on 9/6/23.
The Program Director met with staff on 10/25/23 and reminded staff that they must report all bruises, injuries, or any other concerns to a supervisor or on-call immediately even if they have documented them. All staff were retrained on 10/25/23 by the Program Director on CSG's Abuse and Neglect Policy, Incident Reporting and Management for IDD Services and the Incident Management Bulletin and CSG's Who to call for help. See sign in sheet.
The Program Director retrained the point persons on 11/1/23 on CSG's Incident Reporting and Management for IDD Services and on the ODP Incident Management Bulletin with a specific focus on the requirement to notify family within the required time frame. See sign in sheet. |
11/02/2023
| Implemented |
| 6400.18(f) | Individual #1 had unexplained injuries noted by staff as early as 9/1/23. This was later determined to be the result of physical abuse. The target staff member continued to work in Individual #1's home until the morning of 9/6/23. Additionally, a report to Adult Protective Services was not made until 9/20/23, and a report to law enforcement was not made until 9/25/23. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | On 9/5/23, DSP staff reported bruising and injuries to Individual #1. An EIM incident was filed for Unexplained injuries. Individual #1's family was notified of the incident on 9/5/23. A Certified Investigation was started on 9/6/23 to look into the Unexplained Injuries on Individual #1. When the Investigator was completing witness statements with DSPs, an allegation was made by DSPs that the bruising may have been caused by a specific staff member and an allegation of Abuse was made. The target of the abuse allegation was suspended immediately on 9/6/23.The EIM incident of Unexplained Injury was updated to an Abuse Incident and Abuse Investigation. The 9/1/23 documentation on individual#1's body chart was not discovered until after the investigation started on 9/6/23.
The Program Director met with staff on 10/25/23 and reminded staff that they must report all bruises, injuries, or any other concerns to a supervisor or on call immediately even if they have documented them. All staff were retrained on 10/25/23 by the Program Director on CSG's Abuse and Neglect Policy, Incident Reporting and Management for IDD Services and the Incident Management Bulletin, and CSG's Who to call for help document.
The Director of IDD Services retrained the Program Director and Point person on 11/2/23 on the Incident Management Bulletin specific to when to contact adult protective services and law enforcement. See sign in sheet. |
11/02/2023
| Implemented |
| 6400.18(g) | Individual #1 had unexplained injuries noted by staff as early as 9/1/23. A certified investigation was not started until 9/6/23. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | On 9/5/23, DSP staff reported bruising and injuries to Individual #1. An EIM incident was filed for Unexplained injuries. Individual #1's family was notified of the incident on 9/5/23. A Certified Investigation was started on 9/6/23 to look into the Unexplained Injuries on Individual #1. When the Investigator was completing witness statements with DSPs, an allegation was made by DSPs that the bruising may have been caused by a specific staff member and an allegation of Abuse was made. The target of the abuse allegation was suspended immediately on 9/6/23.The EIM incident of Unexplained Injury was updated to an Abuse Incident and Abuse Investigation. The 9/1/23 documentation on individual#1's body chart was not discovered until after the investigation started on 9/6/23.
The Program Director met with staff on 10/25/23 and reminded staff that they must report all bruises, injuries, or any other concerns to a supervisor or on call immediately even if they have documented them. All staff were retrained on 10/25/23 by the Program Director on CSG's Abuse and Neglect Policy, Incident Reporting and Management for IDD Services and the Incident Management Bulletin. See sign in sheet.
The Director of IDD Services retrained the Program Director and Point person on 11/2/23 on the Incident Management Bulletin specific to the requirement to initiate an investigation within 24 hours of discovery of a staff person. See sign in sheet. |
11/02/2023
| Implemented |
| 6400.52(c)(6) | Reviews of staff schedules for the home were completed for 7/1/23 through the present. A total of 12 staff worked in the home during this time. In addition to individual plan and protocol training, Individual #1's Individual Support Plan (ISP) indicates that all staff supporting Individual #1 are to be trained in Autism and Aggressive Behaviors.
· Staff persons #1, #5, #10, and #12 have not received training in Individual #1's ISP.
· Staff persons #2, #7, and #8 have not received training in Individual #1's ISP or autism and aggressive behaviors.
· Staff persons #3, #4, and #11 received training in Individual #1's ISP on 9/27/23. Staff persons #3, #4, and #11 worked with Individual #1 before this date and have also not been trained in autism and aggressive behaviors.
· Staff person #9 received training in Individual #1's ISP on 9/27/23. This staff person worked with Individual #1 before this date. | 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. | The Program Director met with the house supervisor and Program Manager of the home to review the importance of meeting with all staff at time of hire to review all person specific support plans, protocols, and individual specific training. They were reminded that staff must be trained in the individual ISP prior to working with the individual. This occurred on 11/1/23. See sign in sheet. All staff were trained in person by the Program Specialist on Individual #1's Support Plan, assessment, safety and supervision levels, protocols on 10/25/23. The Behavior Specialist retrained all staff on 10/25/23 on the Behavior Plan. See sign in sheet. |
11/02/2023
| Implemented |
| 6400.186 | The Behavior Support Plan included in Individual #1's Individual Support Plan (ISP) indicates that Individual #1 requires 2:1 supervision at all times. Both staff are to remain on the same floor as Individual #1, one staff always within line of sight, during waking hours. During sleeping hours, one staff can be downstairs sleeping while the second staff remains awake on the same level of the home as Individual #1. Staff persons #6, #9, and #12 all report in witness statements that staff person #5 is always on a different floor of the home, even during awake hours, not maintaining proper supervision levels in the home. Additionally, Individual #1's ISP indicates that if Individual #1 is asleep, staff are to monitor the bedroom door and observe Individual #1 directly every 15 minutes. Daily logs note that staff are checking on Individual #1 every hour at night, not every 15 minutes as required by the plan. | The home shall implement the individual plan, including revisions. | The Behavior Specialist retrained all staff on 10/25/23 on the Behavior Plan. All staff were trained in person by the Program Specialist on Individual #1's Support Plan, assessment, safety and supervision levels, protocols on 10/25/23. |
11/02/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of the inspection, the mechanical ventilation system in the upstairs bathroom had a large collection of dust covering the entire vent cover. The bathtub/shower wall were not clean. It had black dirt/marks all over it. | Clean and sanitary conditions shall be maintained in the home. | The bathroom inside the home was cleaned and the vent was cleaned thoroughly by the contractors on Friday February 11th, 2022. Staff have been communicated with to ensure they are cleaning all surfaces and areas of the home each day and that vents are not being missed while cleaning at any time. The pictures of these cleaned and sanitary conditions with the dust on bathroom vent cleaned and contractors invoice are attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.67(a) | At the time of the inspection, in the upstairs bathroom, the paint above the wall of the shower was peeling away from the wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | The shower paint around the shower panels at the home was repaired by the contractors in the upstairs bathroom on Friday February 11th, 2022. The pictures of these repairs and contractors invoice are attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.68(c) | The coliform test was completed late. It was completed on 9/27/21 and not again until 1/22/22. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The Well Water Test is scheduled to be completed within the required time frame of the last Quarterly Well Water Test and will be completed by the due date. Google Calendar Invites have been created for this date to ensure the Well Water Tests are being completed within the required time frames each quarter. |
04/30/2022
| Implemented |
| 6400.77(c) | While conducting the on-site inspection on 2/10/22 the first aid manual was missing and not with the First aid kit. | A first aid manual shall be kept with the first aid kit. | A new First Aid Manual was purchased and placed inside the First Aid Kit at the home on 03/02/2022. Staff were retrained on 03/02/2022 on the need to physically and visually be checking for the First Aid Manuel inside the First Aid Kit each month during the Monthly Fire Drill and they will be ensuring the Manual is available at the house each month moving forward. The picture of the new First Aid Manual being inside the First Aid Kit is attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.141(c)(12) | Individual #1's most recent physical completed on 8/10/21 had this section blank. | The physical examination shall include: Physical limitations of the individual. | The physical examination sections and what needs to be entered onto forms during the Physical Examination was reviewed with all Manager, Specialists and Supervisors from the ASD Program to ensure we are not having these same issues again during all new and upcoming Physical Examinations. There is an updated Physical Exam Form with all required documentation attached from a Physical Exam that took place during the licensing time frame showing the corrections and how we will ensure all Physical Examinations are completed and documented correctly moving forward. |
04/30/2022
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent physical completed on 8/10/21 had this section blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination sections and what needs to be entered onto forms during the Physical Examination was reviewed with all Manager, Specialists and Supervisors from the ASD Program to ensure we are not having these same issues again during all new and upcoming Physical Examinations. There is an updated Physical Exam Form with all required documentation attached from a Physical Exam that took place during the licensing time frame showing the corrections and how we will ensure all Physical Examinations are completed and documented correctly moving forward. |
04/30/2022
| Implemented |
| 6400.143(a) | (Repeat from Inspection dated 2/1/21) Individual #1 had a scheduled dental appointment on 9/17/21 but was made to wait for the dentist for 1 hr and Individual #1 refused to be seen. The appointment was rescheduled for 12/27/21, but Individual #1 refused to go to the appointment. Individual #1 has refused other appointments. There is no plan in place in the record. There is no documentation the Individual was trained on the importance of attending dental appointments. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A Desensitization Plan was created for Individual #1 by the Behavior Specialist and all staff were trained on the Desensitization Plan and how to work on this plan and document the records from this plan if any refusals of appointments would take place. The new plan was implemented and all staff were trained on the plan on 03/02/2022. The new Desensitization Plan and the training showing all staff have been trained on this new Desensitization Plan is attached to this Plan of Correction. |
05/31/2022
| Implemented |
| 6400.34(b) | Individual #1's rights were reviewed on 9/3/20 and again on 5/25/21. Neither Individual #1 nor Individual #1's guardian signed the Individual Rights that were dated 5/25/21. CSG had noted that Individual #1's guardian was sent the Rights on 5/25/21 but was asked not to sign the Rights due to safety procedures in place for Covid-19. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The individual's rights were reviewed with Individual #1 and the individual's mother/legal guardian on March 9th, 2022 and a signature was collected by the Legal Guardian with the updated rights. The Program Specialist will review all other records to ensure signatures from the individuals and their legal guardians are on file and create updated rights documents in the Electronic Health Record with signatures by 4/30/2022. The new Annual Rights document that was completed and signed by the Individuals legal guardian is attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.165(g) | (Repeat from Inspection dated 2/1/21) The quarterly psychiatric medication reviews dated 6/1/21, 7/2/21, and 10/21/21 do not contain the reason why the following medications were prescribed for Individual #1: Thorazine 100mg tab twice a day, Thorazine 50mg 1 tab at noon, Depakote ER 500mg 4 tablets at bedtime, Depakote Er 250mg 1 tab at bedtime, Clonidine 0.1mg 1 tab 3xs day, NAC 600mg 3 caps twice day, Benztropine 1mg 2xs day. The form lists IDD, Bipolar and Autism Spectrum. This is not the reason why each medication is prescribed. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | All staff members, supervisors, managers and specialists were retrained on 03/02/2022 on the required items that are needed on all Psychiatric Medication Review Forms and that the Supervisor and Manager are responsible to ensure that all Medical Appointment Forms have the correct and required information listed and documented. Attached is a Quarterly Psychiatric Medication Review Appointment Form that took place after Licensing to show the form completed with the required information and this will be how all Quarterly Psychiatric Medication Review Forms will be completed moving forward to ensure no further issues take place with this regulation. We also had communication with the Psychiatrist to ensure that they understand what information we need completed for each form and the need for required doctor's signatures and dates on each form. |
04/30/2022
| Implemented |
| 6400.186 | Individual #1's current assessment completed on 6/19/21 under the section Knives/Sharps- Level of Supervision- it states that: Individual #1 can use safety scissors but does not have open access to sharps in the home. The team is unsure if Individual #1 would take sharp knives and start to flick or flap as they do with straws/cardboard tubes and other objects. While conducting the in person walk-through inspection of the home on 2/10/22 the inspector saw a large knife approximately 7 inches in length in the drawer in the kitchen by the sink. Individual #1 would have access to if the drawer was opened. There was no lock on the drawer to prevent access. All other knives where locked in a closet. | The home shall implement the individual plan, including revisions. | All staff at the home were retrained on the supervision levels and retrained on the requirement of all sharps and knives being kept locked at all times inside the group home on 3/02/2022. All sharps are required to be locked at all times in the home and can be kept locked inside the hallway closet. Staff were re-trained on the need to clean all knives and sharps immediately by hand washing after use moving forward so these items can be placed back inside the locked hallway closet and not accessible by the individual. The Manager walked through the home and made sure all knives and sharp objects were locked in the hallway closet on 3/02/2022. The retraining on the ISP that was completed with all staff members is attached to this Plan of Correction as well as images of the locked sharps from the home. |
05/31/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | At the time of the inspection on 1/7/19, Individual #1 had a physical examination completed on 9/12/17 and none since then. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Supervisor secured a copy of the individual's annual physical from the primary care physician and added it to the record. The annual physical was completed on time, but paperwork was not in the record. The Program Supervisor/Manager will conduct a record review and verify individual's physicals are in the record by 5/31/19. The Program Supervisor/Manager will be responsible for ongoing monitoring to ensure annual physicals are added maintained in the individual's record. The Program Supervisor's/Manager's/Specialist's and DSP's will be retrained on the regulation by 5/15/19. Please see attachment #4 for the annual physical. |
05/31/2019
| Implemented |
| 6400.144 | REPEAT from 9/18/17 annual inspection: Individual #1 did not attend their scheduled psychiatric appointment on 11/02/18 due to staff reporting that staff was unaware of the appointment. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The Program Supervisor/Manager took the individual to the next available psychiatric medication review. The Program Supervisor/Manager will be responsible to share appointments that are scheduled electronically. The Program Supervisor/Manager will verify all individual appointments have been shared by 5/31/19. The Program Supervisor/Manager will be responsible for ongoing monitoring and completion of scheduled client appointments. all Program Supervisor's/Manager's/Specialist's and DSP's will be retrained in the regulation by 5/15/19. Please see attachment #3 for psychiatric medication review. |
05/31/2019
| Implemented |
| 6400.163(c) | REPEAT from 9/18/17 annual inspection: Individual #1's 11/21/18 psychiatric medication review did not include a review of the medication dosages prescribed to the individual. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Program Supervisor included a medication list at the individual's next psychiatric medication review and included that in the individual's record. A record review will be completed by the Program Manager/Supervisor by 5/31/19 to verify medications were documented on psychiatric medication reviews. All Program Supervisor's/Manager's/Specialist's and DSPs will be retrained on this regulation by 5/15/19. The Program Supervisor/Manager will be responsible for ongoing monitoring and completion of psychiatric medications forms at they occur. Please see attachment #3 for psychiatric medication review. |
05/31/2019
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) does not identify their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | The Program Specialist coordinated the update of the ISP with Supports Coordination to add vocational information to ISP. A record review of all individuals will be conducted by the Program Specialist to verify that individuals ISPs reflect vocational information by 5/31/19. All Program Specialist's will be retrained in regulation by 5/15/19. The Program Specialist will be responsible for ongoing monitoring of this regulation at the time of the annual ISP. Please see attachment #2 for the updated ISP section. |
05/31/2019
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) does not identify their potential to advance in Competitive Community Employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| The Program Specialist coordinated the update of the ISP with Supports Coordination to add competitive community integrated employment information to ISP. A record review of all individuals will be conducted by the Program Specialist to verify that individuals ISPs reflect competitive community integrated employment by 5/31/19. All Program Specialist will be retrained in regulation by 5/15/19. The Program Specialist will be responsible for ongoing monitoring of this regulation at the time of the annual ISP. Please see attachment #2 for the updated ISP section. |
05/31/2019
| Implemented |
| 6400.213(11) | REPEAT from 9/18/17 annual inspection: Individual #1's current Individual Support Plan (ISP) updated on 7/25/18, identifies a diagnosis of Impulse Control Disorder however, the current assessment does not identify this diagnosis. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The Program Specialist added impulse control disorder to the individual¿s annual assessment. A record review of all individuals will be conducted by the Program Specialist to verify diagnoses documented in the assessment match active diagnoses in electronic health record when creating assessment by 5/31/19. All Program Specialist will be retrained in regulation by 5/15/19. The Program Specialist will be responsible for ongoing monitoring of this regulation at the time of annual assessment. Please see attachment #1 for the updated annual assessment. |
05/31/2019
| Implemented |
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