| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(4) | ARC assessment dated 2/8/20 indicates that "Individual #1 requires full 24-hour supervision both at the home and in the community due to limited safety practices and skills." The Individual Service Plan (ISP) notes her required supervision to be "Supervision Care Needs: "Individual #1 continues to need 24 hour supervision at home because of limited safety practices and awareness. There are no plans to start alone time because of Individual #1's limited safety skills." and is further detailed as "Individual #1 eats independently, but needs to be supervised and have staff at the table with her." Assessments are to be person specific plans that address the specific needs of the person. An individualized assessment is required to satisfy the regulation.
The Individual Service Plan (ISP) states in the "Meals and Eating" section that "Individual #1 eats independently, but needs to be supervised and have staff at the table with her. She needs to have her food cut into small presentation sized pieces for her by staff. She needs to take small bites when eating and needs." The assessment dated 2/8/20 does not note that additional supervision is required while eating. | The assessment must include the following information: The individual's need for supervision.
| It is the responsibility of the Program Specialist to ensure that information contained in the ISP and assessment is accurate and consistent with one another. Program Specialists will review all individual files on their case loads and verify all is true and accurate. This process will be ongoing and ISP's will be updated when there is revisions to assessments. DSP's that work with individuals will be trained on the supervisory needs for both health and safety prior to working with individuals and after yearly reviews of ISP's. CLA supervisors are responsible for this training and a new ISP training has been developed. Also during the time of orientation, a you tube video will be showed pertaining to food consistencies. ISP training form attached. |
03/18/2021
| Implemented |
| 6400.181(e)(10) | The assessment dated 2/8/20 did not contain a Lifetime Medical History. A Lifetime medical history is required. | The assessment must include the following information: A lifetime medical history. | As per regulation 6400.181 e (10), all individuals residing in Arc CLA's shall have a Lifetime Medical History attached to the assessment and it will be updated yearly or as necessary. Program Specialists will review their case loads and ensure that individuals Lifetime Medical histories are attached and updated. The Program Manager of Residential Services will review with the Program Specialists information to be included individual files and documentation of such training will be kept on file. |
03/18/2021
| Implemented |
| 6400.181(e)(13)(i) | The ARC assessment dated 2/8/20 included a section titled "Progress Toward: A. Health:" This section of the assessment notes three hospitalizations for low sodium levels and a fluid restriction that occurred in 2019 but contains no reference to the choking incident that occurred on 3/16/19. The "Health" section is an incomplete assessment on the current progress and current level in health over the last 365 calendar days. | 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.
| Information listed in the assessments are to accurate and true in accordance to regulation 6400.181 e (13) i. It is the responsibility of the Program Specialist to ensure that medical events that happen throughout the calendar year, are documented in the health area section of the assessment. The information with be reviewed by both the Program Specialist and CLA supervisor. Such information will be updated no later than 24 hours post discharge from a hospitalization. |
03/18/2021
| Implemented |
| 6400.46(d) | Staff #2 received initial training on CPR/First Aid on 8/13/19. The Arc description of this training is documented as "First Aid(video) also includes CPR (non-test). No additional training followed. Annual training by a certified instructor is required. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | All Direct Support Professionals and well as Program Specialists, shall receive training within 6 months of hire and annually thereafter, by a certified instructor in the areas of CPR, first-aid, and Heimlich techniques. Staff #2 received First-aid, CPR, and AED training on 3/10/2021 and will receive it annually thereafter. The CLA supervisor and Program Specialist are to ensure compliance of this regulation. Supporting documents attached. |
03/18/2021
| Implemented |
| 6400.52(c)(6) | The Arc training records provided: "ISP Review Acknowledgment Form" dated 8/10/19 was the only documentation of annual training on the ISP for Individual #1 conducted for Staff #1. There is no record of annual training being completed in 2020 as is required. | 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. | All DSP's that work will individuals must complete an initial training and then yearly thereafter on individuals ISP's. Staff #1 has been trained on all residents ISP's and documentation is noted. It is the responsibility of both of the CLA supervisor and Program Specialist the ensure compliance to this regulation. A new ISP training form has been created to further assist in making sure all areas of the ISP is reviewed. Form attached. |
03/18/2021
| Implemented |