Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.111(a) | REPEAT 12/07/16- Individual # 1's annual physicals were late. Physical dated 03/8/16 and 05/24/17. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Manager and Program Nurse are responsible for the following actions: Letters will be sent home 45 and 30 days prior to physical being due. Phone calls to participant or family/ caregivers alerting them that they will not be able to attend the day program if their physical is not turned in on time will be made 15 days prior to physical expiration date. Continued use and maintenance of tracking log to alert nurse and manger when physicals are coming due. |
01/30/2018
| Implemented |
2380.111(c)(1) | Individual # 2's physical dated 08/15/17 does not indicate that the physician reviewed the medical history | The physical examination shall include: A review of previous medical history. | Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. |
01/30/2018
| Implemented |
2380.111(c)(7) | Individual # 2's physical dated 08/15/17 does not assess health maintenance needs. Space left blank | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. |
01/30/2018
| Implemented |
2380.111(c)(10) | Individual # 2's physical dated 08/15/17 does not indicated information pertinent to diagnosis in case of an emergency. Individual # 1's physical dated 05/24/17 did not include information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Updates to physical form completed 1/26/18 (attachment #2). Training with program nurse on new physical form and responsibility to check for completeness (completed 1/30/18 ¿ attachment #10). Inglis compliance department to audit for compliance. |
01/30/2018
| Implemented |
2380.113(c)(4) | Staff # 4's 07/21/17 physical exam did not indicated physical limitations or medical problems. Space left blank. | The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals. | Program Director completed training with Occupational Health Department (completed 1/30/18 ¿ attachment #9). Inglis compliance department will audit for compliance. |
01/30/2018
| Implemented |
2380.173(6)(ii) | No signature page for Individual # 2's ISP meeting on 10/13/17 contained in record | Each individual¿s record must include the following information: A copy of the signature sheet for: The annual update meeting. | When Inglis attends ISP meeting, Program Manager and Director are responsible for making a copy of the signature page is made after the meeting ends. When Inglis does not attend, but is aware the meeting occurred, they will request a signature page from SC via email. The email will be printed and made part of the record. Inglis Compliance office will Audit for compliance. |
01/30/2018
| Implemented |
2380.173(7) | Individual # 1's current ISP was not contained in the record. | Each individual's record must include the following information: A copy of the current ISP. | Program Director completed audit of charts ¿ all participant records updated with most current version of the ISP (completed 2/2/18). Inglis Compliance department to audit for compliance. |
02/02/2018
| Implemented |
2380.181(e)(3)(iii) | Individual # 2's assessment dated 08/01/17 does not indicate his/her current level of performance and progress in the area of personal adjustment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(5) | Individual # 2's assessment dated 08/01/17 does not indicate his/her ability to self-medicate. Individual #2 is administered all medication by a nurse at the program'. Individual # 1's 11/03/17 assessment does not indicate his/her ability to self-medicate. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(7) | Individual # 2's assessment dated 08/01/17 does not indicate his/her ability to sense and move away 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. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(10) | Individual # 2's assessment dated 08/01/17 does not include a lifetime medical history. Individual # 1's assessment dated 11/03.17 does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | All Lifetime medical histories were removed from their own section of the chart to the Assessment area of the chart. Updates to annual and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education Program Nurse on where to file Lifetime medical history (completed 2/1/2018 ¿ attachment #8). |
02/01/2018
| Implemented |
2380.181(e)(12) | Individual # 2's assessment dated 08/01/17 does not indicate his/her recommendations for specific areas of training. ) Individual # 1's assessment dated 11/03/17 does not indicate his/her recommendations for specific areas of training | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(13)(i) | Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for 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. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(13)(ii) | Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for 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. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(13)(iv) | Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for Socialization | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.181(e)(13)(v) | Individual # 2's assessments dated 08/02/16 and 08/01/17 are the same (verbatim). Progress and growth during the past year not indicated for Recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.183(3) | The method of evaluating progress towards goals in Individual # 1's current ISP states SC will document progress in monitoring concern sheets. Individual # 1 will go out on community outings with his/her staff of his/her choice during the week.' Inglis House not included in evaluation of outcome. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | Email to individual 1¿s SC to request new outcome for day program (attachment #7). Will follow up when response is received. (Note- individual #1 is scheduled to move into LTC in February 2018, so no resolution to this issue may occur). emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. |
01/30/2018
| Implemented |
2380.183(7)(i) | Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in vocational programming. Space left blank. ) Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Updates to Quarterly ISP reviews completed to review this information (completed 1/26/18 - attachment #4)Emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. |
01/30/2018
| Implemented |
2380.183(7)(i) | Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in vocational programming. Space left blank. ) Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Vocational programming. | Program specialists send emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. |
01/30/2018
| Implemented |
2380.183(7)(iii) | Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in competitive community integrated employment. Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in community integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (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. | emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. |
01/30/2018
| Implemented |
2380.183(7)(iii) | Individual # 2's Individual Support Plan (ISP) last updated 10/13/17 does not assess the potential to advance in competitive community integrated employment. Individual # 1's Individual Support Plan (ISP) does not assess the potential to advance in community integrated employment | The ISP, including annual updates and revisions under § 2380.186 (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. | emails to Supports coordinators as needed to make recommended changes to the ISP. Records of these correspondences will be printed and kept on the record. Program Manager and Program Specialist are responsible for this action. |
01/30/2018
| Implemented |
2380.186(a) | Individual # 1's ISP reviews for the annual review year do not include review of outcome socialization'. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.186(b) | ) Individual # 2 did not sign quarterly review on 11/02/16, 02/02/17 or 05/01/17. Individual # 1 did not sign quarterly reviews on 02/07/17, 05/05/17, 08/04/17 and 09/07/17. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.186(c)(1) | Program Specialist indicated that Individual # 1 is working on an outcome to socialize at day program. Monthly documentation states Individual # 1 socialized today'. No details of support or services provided to Individual # 1. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.186(c)(2) | Individual # 2's ISP reviews dated 08/01/17, 05/01/17, 02/02/17 and 11/02/16 do not include reviews of seizures (protocol/frequency). ISP review dated 05/01/17 did not include the health updated of an illness described in 03/03/17 progress note. 08/01/17 review did not include 07/10/17 progress note of individual # 2 coming to program with abrasions. 3 seizures occurred on 03/03/17 at the program without documentation in reviews. The meaningful day outcome was not reviewed as per no documentation of the tracking of Individual # 2's engagement in activities while at the program two times per day. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (completed 2/2/2018 ¿ attachment #5). Phase in new documentation starting 1/26/2018, (to be completed 5/1/2018). |
05/01/2018
| Implemented |
2380.186(d) | No documentation that Individual # 2's ISP reviews were sent to team members within 30 days of meetings. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | When Inglis is made aware of the ISP meeting, Program Manager is responsible for sending Annual Assessment and newly formatted quarterly ISP reviews to the SC at time of notification of ISP meeting. All communications are done via email, and will be printed and placed in the participant record to document the communication. |
02/02/2018
| Implemented |
2380.186(e) | No option to decline Individual # 2's ISP reviews contained in record. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Issue 8: Program Manager and Program Director are responsible to collect this information at ISP¿s meetings when possible. Form created to allow for option to decline (attachment #6) |
02/02/2018
| Implemented |
2380.188(a) | - Individual # 1 has a seizure disorder. There is no seizure protocol in place. | The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | Program Manager and Program nurse are responsible for the following actions: create a seizure protocol form (completed 1/2/2018 ¿ attachment #1). Update all participant records with a seizure protocol if needed (completed 1/12/18). Physical Form updated to collect seizure protocol at time of admission and annually (completed 1/26/18 ¿ attachment #2). Complete seizure training with all program staff at least annually (completed 1/2/18 ¿ attachment #3). |
01/26/2018
| Implemented |
2380.188(b) | No documentation that Individual # 1 and Individual # 2 were provided services for participation in community life. | The facility shall provide opportunities and support to the individual for participation in community life, including work opportunities. | Updates to annual assessment and quarterly ISP review forms (completed 1/26/18 ¿ attachment #4). Training and education to all staff who complete annual and quarterly review documentation (scheduled 2/2/2018 ¿ attachment #5). Phase in new documentation starting 2/1/2018, to be completed 5/1/2018). |
05/01/2018
| Implemented |