| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(7) | The Health Maintenance Needs section was blank on Individual #2's physical exam dated 9/12/2018. | 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. | The health and maintenance section of Individual #2's physical has been updated. Agency LPN will send a memo to all providers and families recommending they complete as much of the non-medical sections of the physical form as possible prior to the appointment. Upon receipt of program participants annual physicals, both the agency LPN and the individual's Program Specialist will review the record to ensure all sections are completed to satisfy this plan of correction. |
02/22/2019
| Implemented |
| 2380.181(e)(13)(ii) | Progress & growth was not noted in the area of Communication on Individual #1's assessment dated 9/3/2018. | 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. | Individual #1's assessment has been updated in the communication section. Within 60 day after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. |
02/22/2019
| Implemented |
| 2380.181(e)(13)(iii) | Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018 | 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. | Individual #1's assessment has been updated in the personal adjustment section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. |
02/22/2019
| Implemented |
| 2380.181(e)(13)(iv) | Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018. | 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. | Individual #1's assessment has been updated in the socialization section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. |
02/22/2019
| Implemented |
| 2380.181(e)(13)(v) | Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018 | 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. | Individual #1's assessment has been updated in the recreation section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. |
02/22/2019
| Implemented |
| 2380.181(e)(13)(vi) | Progress & growth was not noted in this area on Individual #1's assessment dated 9/3/2018 | 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. | Individual #1's assessment has been updated in the community-integration section. Within 60 days after admission and annually thereafter, the Program Specialist will complete/update progress in all required sections of the individuals assessments, or as needed based on functional changes that may occur. Assessments will be part of random audits to be completed by the Program Manager to ensure compliance with regulations and this plan of correction. |
02/22/2019
| Implemented |
| 2380.186(b) | Individual #3 did not sign her ISP Reviews dated 7/10/2018 and 10/10/2018. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Individual #1 has since signed her ISP. Upon review of the quarterly review with the program participants, Program Specialists will ensure that the individuals are aware of their progress made on goals specified in their ISP by way of their signature. Random audits of program participants file shall be completed by the Program Manager to ensure compliance to this plan of correction. |
02/22/2019
| Implemented |