Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.58(a) | The drawer on the entertainment center in the program area was missing a knob. | Floors, walls, ceilings and other surfaces shall be in good repair. | it is important for all surfaces be in good repair to ensure the health and safety of all members. At the time of the inspection the knob from the entertainment center was missing. On 11/12/2018 the knob was replaced with a new functioning knob. (Attachment # 5) The Center Director will do a walkthrough of the center on a weekly basis to ensure all surfaces are in good repair and contact the handyman to complete repairs if necessary. |
11/12/2018
| Implemented |
2380.111(c)(10) | Individual #1's physical exam dated 6/28/2018 did not indicate if there was any medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | It is important to have a current physical for all person supported within the program in order to ensure their health and safety. Individual #1 physical did not include information regarding his medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 physical was updated 11/14/2018 that states that call 911 in case of emergency. (Attachment #3) The Program team will review the physical and the ISP document to ensure accuracy of both documents upon receipt. If documents are found to have discrepancies they will document their findings and follow up with the appropriate parties to obtain accurate information. The RN and Center Director were both trained on their responsibility on 11/5/2018 (Attachment #4) on meeting their responsibility in meeting the regulation. The Center Director will review a 10% sample every 3 months and complete a sign off form to show compliance |
11/14/2018
| Implemented |
2380.181(d) | Individual #1's Annual Assessment does not have the complete date (month, day & year). | The program specialist shall sign and date the assessment. | The Program Specialist was trained on completion of assessments on 11/5/2018 and she will ensure that all Assessments for all members are signed and dated in the future. (Attachment #1) |
11/05/2018
| Implemented |
2380.181(e)(12) | Individual #1's Annual Assessment dated 6/2018 does not include Recommendations for additional training. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The program specialists updated the assessment for individual #1 to include recommendations for areas of training, vocational programming and competitive community-integrated employment. (Attachment #2) |
11/14/2018
| Implemented |
2380.181(e)(13)(v) | Individual #1's Annual Assessment dated 6/2018 does not include progress and growth in the area of 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. | The Program Specialist updated the assessment for individual #1 to include progress over the last 365 calendar days and current levels in the following areas: Recreation (Attachment 2) |
11/14/2018
| Implemented |
2380.181(e)(13)(vi) | Individual #1's Annual Assessment dated 6/2018 does not include progress and growth in Community Involvement. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Specialist updated the assessment for individual #1 to include progress over the last 365 calendar days and current levels in the following areas: Community Involvement (Attachment #2) |
11/14/2018
| Implemented |