| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | Emergency evacuation plan does not describe individual and staff responsibilities in an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Individual #1s personal emergency evacuation plan was amended by RPD, on 6/30/21, to include specific staff and individual responsibilities. All other individuals emergency evacuation plans were reviewed by RPS for the presence of specific, personalized responsibilities of staff and individuals by 7/16/21. All evacuation plans lacked specific individual responsibilities. All individual emergency evacuation plans were updated with individual responsibilities on 7/14/21 by the RPS, using the blank outline for an individualized emergency evacuation plan. RPD reviewed each individual evacuation plan for the inclusion of personalized responsibilities of individual and staff on 7/20/21. An updated, blank outline of an individualized emergency evacuation plan was created by RPD on 6/30/21 and saved on the shared documents folder for agency wide usage. RPD also emailed the new outline of an individual emergency evacuation plan, along with instructions, to agency management for agency wide usage on 7/13/21. See attachments #1a, #1b, #1c and #1d. |
10/01/2021
| Implemented |
| 6400.141(c)(9) | The 7/20/20 annual physical does not include a record of a prostate exam being completed. The 5/29/19 annual physical states, in reference to the prostate exam, "pt uncooperative". There is no record of a prostate-specific antigen (PSA) test being completed; a physician note on the annual physical indicates that neither a PSA nor a manual exam were completed due to Intellectual Disability. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 is diagnosed with hypersensitivity and tactile defensiveness. Digital prostate exams would not be appropriate in this situation. PSA testing orders will be obtained from the PCP on 7/26/21, with his annual physical. Other male individuals physicals were reviewed by RPS on 7/14/21 for the absence of a prostate exam. No deficiencies found. The current agency annual physical form contained the phrase Prostate Digital Exam (men 40 years or older) for the physician to comment on. This item on the physical was changed to Prostate Digital Exam or PSA levels if appropriate (men 40 years or older)¿ on 7/12/21 by RPD. A copy of the updated physical was added to the shared documents file and emailed to agency management along with instructions, for agency wide usage, on 7/13/21, by RPD. See Attachments #2a and #2b. |
10/01/2021
| Implemented |
| 6400.212(a) | Individual #2 08/27/20 ISP is stapled to Individual #1 08/26/20 ISP and kept in Individual #1 program book. | A separate record shall be kept for each individual.
| The former housemates ISP was removed from Individual # 1s record on 6/30/21 by RPS. All other records will be reviewed by RPS to ensure all individual records only contain information exclusively for the individual that the record was intended for and contained no other individuals information on 7/14/21, 7/15/21, and 7/16/21. No other deficiencies were found. RPD created a checklist, on 7/12/21, for RPS to utilize monthly, for 3 consecutive months, ensuring all individuals¿ information is kept separate from one another. RPD will review checklist monthly for completion. RPD emailed to agency management for agency wide usage, along with instructions, on 7/13/21. See Attachments #3a and #3b. |
10/01/2021
| Implemented |
| 6400.181(f) | Individual #1 Annual Assessment was completed and sent to the ISP team on 07/02/21, not at least 30 days prior to ISP meeting conducted 07/28/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | RPS reviewed all individuals¿ current Assessments for the date they were documented to be provided to the SC, on 7/16/21. Upcoming assessments, including assessments for individual #1, were emailed to SCs on 7/6/21 by RPD. An ISP meeting Date was then decided upon by the SC and RPD for those individuals whose assessments were sent. The ISP meeting day is scheduled for 8/11/21, which more than 30 days from when the assessments were sent to the SC. RPD created a chart for due dates, including the completion date of each assessment, latest date assessment should be provided to SC, and an item to indicate what date the upcoming ISP meeting must be completed by to meet the requirements of the assessment being provided to SC 30 days (or more) prior to the ISP meeting. RPS documented the review of the current and upcoming assessments on aforementioned chart. A copy of the chart was emailed to each individuals respective SC by 7/20/21, by RPD, as a guideline to follow for scheduling future ISP meetings. The chart for assessment completion dates/ ISP meeting dates was emailed to agency management by RPD on 7/13/21 for agency wide usage. This chart was also saved to the shared documents folder, by RPD on 7/13/21, so that it is available to all agency management for use. See Attachments #4a, #4b and #4c. |
10/01/2021
| Implemented |