Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.181(e)(13)(ii) | There was no progress and growth listed on Individual #1's assessment dated 10/18/13 in the arears of communications or residential living. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (iii) Activities of residential living.
| Individual #1¿s assessment was amended to include progress and growth specific to motor and communication skills and activities of residential living. A revised, standardized Assessment form was developed and includes the missing skill/progress and growth areas that need to be responded to by the Program Specialist. Training for all Program Specialists on the proper items to be included in the Assessment and on the new form occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process. |
01/31/2014
| Implemented |
6400.181(e)(13)(v) | There was no progress and growth listed on Individual #1's assessment dated 10/18/13 in the arears of socialization or recreation. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (v) Socialization.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation.
| Individual #1¿s assessment was amended to include progress and growth specific to socialization and recreation skills and activities of residential living. A revised, standardized Assessment form was developed and includes the missing skill/progress and growth areas that need to be responded to by the Program Specialist. Training for all Program Specialists on the proper items to be included in the Assessment and on the new form occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process. |
01/31/2014
| Implemented |
6400.181(f) | Individual #1's ISP meeting was held on 10/13/13; the assessment is dated 10/8/13. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Going forward all Program Specialists will ensure that assessments are distributed to the SC and plan team members 30 days prior to an ISP meeting for the development, annual update and revision of ISP¿s. If the Program Specialist is unable to comply with this due to inadequate time notification of the plan meeting by the SC, the Program Specialist will document discrepancy in the individual¿s chart. Oversight of this requirement will be addressed by the Assistant Residential Directors for consistency purposes. Training for Program Specialists included proper protocols for timely dissemination of the Assessment and occurred on 1/23 and 1/24/2014. The Assistant Program Director will monitor the process |
01/31/2014
| Implemented |
6400.186(a) | Individual #1¿s ISP start dated was 1/12/13 The most recent 3-month ISP review was completed on 4/14/13. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP.
| Individual #1's quarterly reviews had not been completed for review quarters 7/12/13 and 10/12/13. The missing reviews will be completed and brought up to date. The program specialist for individual #1 will undergo retraining regarding the necessity to complete quarterly reviews. Additional oversight for the program specialist will be provided by the Assistant Residential Director. |
01/31/2014
| Implemented |
6400.186(c)(1) | Individual #1¿s most recent monthly ISP review was completed 5/13. | (c) The ISP review must include the following:
(1) 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 residential home licensed under this chapter.
| Individual #1's monthly ISP reviews had not been completed from 6/13 through 11/13. The missing reviews will be completed and brought up to date. The program specialist for individual #1 will undergo retraining regarding the necessity to complete monthly reviews. Additional oversight for the program specialist will be provided by the Assistant Residential Director. |
01/31/2014
| Implemented |