| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.124(10) | No current copy of the ISP in the record for the following individuals: #1, #2, #3, #4, #5, and #6. | Each client's record must include the following information: A copy of the current ISP. | Effective August 1, 2017, a policy change was implemented to print and file the ISP each time an update occurs relative to our services. |
08/01/2017
| Implemented |
| 2390.124(12) | Individual #14 ISP updated 4/12/2017 states he has a restriction at the workplace; it states he is to use a single stall bathroom. This is not the case. Individual #15 2/16/2017 updated ISP states he has a restrictive plan in place. He does not. This states he is too have 1:1 supports in the morning upon arriving to program, during lunch hour, and in the PM preparing to leave at the end of the day. His ISP also states he takes the medication Zoloft under the Psych Social section of the plan; however it states he takes the medication Prozac under the medication section of the plan. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Individual #14 ¿ Staff have been retrained to review ISP information for accuracy and if discrepancies are found send a request in the form of a General Update Request to the SC to make the updated changes. PS are further retrained to continue reviewing the ISP until information has been changed by the SC.
Individual # 15 ¿ PS submitted a request to clarify that the ISP should indicate that the restrictive plan is not in place at PCIT.
Individual # 15 ¿ PS alerted the SC to the content discrepancy between the ISP sections regarding medication and requested a formal change. PS has been retrained that all ISP documentation is accurate. |
08/04/2017
| Implemented |
| 2390.151(a) | Individual #15 assessment was completed late 9/9/2015 and not again until 9/28/2016. | Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments, including time frames for completion, was reviewed with all Program Specialists and Client Services Staff. |
08/11/2017
| Implemented |
| 2390.151(e)(2) | Individual #10 assessment completed 6/8/2017 did not include likes, dislikes, and interests. | The assessment must include the following information: The likes, dislikes and interest of client, including vocational and employment interests of the client. | The Assessment for Individual # 10 completed on 6/8/2017 did not include likes, dislikes, and interests including vocational and employment interests of the client.
Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment including likes, dislikes and interests including vocational and employment interests. |
08/11/2017
| Implemented |
| 2390.151(e)(3)(ii) | No progress in the area of acquisition of vocational functional skills noted in the current assessments for individual #14. | The assessment must include the following information: The client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions. | Noted that under Correction Required; the client's current level of performance and progress in the following areas: Communication; ability to receive, retain and carry out instructions is noted. However, in a review of the records the citation for Individual #14 is under ¿acquisition of vocational functional skills¿ to which we acknowledge is deficient. Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment to include acquisition of vocational functional skills. |
08/11/2017
| Implemented |
| 2390.151(e)(5) | Individuals #9, #11, and #17 current assessments does not state the ability to self-medicate. | The assessment must include the following information: The client's ability to self-administer medications. | Individual #9, #11 and #17
Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment to include the ability to self medicate. |
08/11/2017
| Implemented |
| 2390.151(e)(7) | Individuals #6, #9, #11, #12 current assessments did not include their ability to move away from heat sources. | The assessment must include the following information: The client's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Individual #6, #9, #1 and #12
Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment, including the knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources. |
08/11/2017
| Implemented |
| 2390.151(e)(9) | Individual #14 11/8/2016 assessment does not state his Autism diagnosis. Individual #8 9/28/2016 assessment did not state his functional and medical limitations. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | Individual # 8 Assessment did not include functional and medical limitations.
Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment, including the functional and medical limitations. |
08/11/2017
| Implemented |
| 2390.151(e)(10) | Current assessments for the following individuals did not include a medical history: #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, and #16. | The assessment must include the following information: A lifetime medical history. | Assessments for the following individuals did not include a medical history: #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, and #16.
At the recommendation of Licensing Agents, beginning October 1, 2017 a Policy and Procedure change was made to merge the Lifetime Medical History into the Assessment document. The completed document will contain all updated information. All Program Specialists will be trained in this new procedure |
10/02/2017
| Implemented |
| 2390.151(e)(13(ii) | Current assessment for individual #9 did not state progress and growth in the area of motor and communication. | 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 # 9 did not document progress or growth in area of motor and communication.
Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment including motor and communication skills. |
08/11/2017
| Implemented |
| 2390.151(e)(13(iv) | Current assessments for individual #3, #5, and #9 did not state the progress and growth in the area of socialization. | 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 # 3, # 5 and #9 did not state the progress and growth in the area of socialization. Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment including progress and growth in the area of socialization. |
08/11/2017
| Implemented |
| 2390.151(e)(13)(v) | Current assessments for individuals #5 and #9 did not state the progress and growth in the area of vocational skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills. | Individual #5 and #9 did not state the progress and growth in the area of vocational skills. Policy and Procedure regarding the 2390 Regulation 151(a) through 151(f) regarding Assessments was reviewed with all Program Specialists and Client Services Staff. All Program Specialists were re-trained in the requirements of an Assessment including the documentation of progress and growth in the area of vocational skills. |
08/11/2017
| Implemented |
| 2390.151(f) | Assessment not sent to individual #11 8/2/2016; assessment not sent to Day Program and Advocate for individual #5 1/24/2017; assessment not sent to individual #9 11/15/2016. | The program specialist shall provide the assessment to the SC or plan lead, 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). | To ensure all team members receive a copy of the Assessment, including the individual, a Policy Change has occurred effective August 11, 2017. This change, made for the individual service recipient will include the name being added to the ¿copies sent to¿ section at the end of the Assessment. For other team members, the staff have been retrained in current procedure to ensure all members receive a copy. |
08/11/2017
| Implemented |
| 2390.153(5) | Individuals #9 and #15 currently takes psychotropic medications and do not have a SEEN plan in place. | A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Individual # 9 and #15
Staff have been retrained on the need for an adequately documented SEEN (social, emotional and environmental needs) Plan in the ISP and in quarterly ISP reviews. |
08/04/2017
| Implemented |
| 2390.153(7)(i) | Individual #1 and #7 current ISP does not state the potential to advance in Vocational Programming. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming. | Staff have been retrained on the need to review the ISP to ensure that each section pertaining to 2390 services are included and accurate. If discrepancies or lack of information are noted, current policy that a General Update Request is submitted to the SC to request the additional information be added to the ISP in the appropriate section. |
08/04/2017
| Implemented |
| 2390.153(7)(ii) | Individual #1 and #7 current ISP does not state the potential to advance in Competitive Community-Integrated Employment. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment. | Staff have been retrained on the need to review the ISP to ensure that each section pertaining to 2390 services are included and accurate. If discrepancies or lack of information are noted, current policy that a General Update Request is submitted to the SC to request the additional information be added to the ISP. |
08/04/2017
| Implemented |
| 2390.154(a) | Individual #11 ISP meeting 11/2/2016 did not have a direct care team member participate. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2390.156 (relating to ISP review and revision). | Individual #7 (corrected from #11)
The Direct Service Worker was not in attendance at the full Annual ISP meeting, however participated in the development, review and planning. We feel we remain in compliance with both the 2390 Regulations/LII and the ODP Memo 037-13. The Regulation 2390.154(a)(1)(iii) states ¿A plan team must include as its members the following:¿¿ ¿A direct service worker who works with the client from each provider delivering a service to the client.¿
The plan team includes the Direct Support Professional (DSP), this staff participated in Goal Planning Review for the Initial Trial Period on 3/9/2016, then monthly on 4/5/2016, 5/2/2016, 6/8/2016, 7/1/2016, 8/1/2016, 9/1/2016, 10/4/2016 and 11/1/2016 to monitor the new goal as documented on the signed and dated progress notes as part of the annual ISP preparation.
Further the DSP met with the PS in advance of the ISP meeting on 11/2/2016 to review any changes or updates needed using the internal PCIT Meeting Preparation Form.
The LII 2390.154(a)(1)(iii)states ¿Does the plan team include a direct service worker that works with the individual and any other person the individual invites? Explanation: Every effort should be made for the identified service workers who work with the individual to attend and participate in the ISP, ISP Annual Update, ISP revision meetings?¿ Although we make every effort, I see no requirement that the direct service worker be in attendance at the ISP, they are in attendance for each quarterly review, therefore are always part of the ISP Plan team.
The ODP Informational Memo 037-13 we use for rules about attendance was issued in 2013 to clarify the Regulation. It states the Program Specialist is the only required plan team member to attend. The Direct Support Professional does meet monthly with the PS to review goals and progress and then directly before the Annual ISP Meeting to participate in the development of the ISP. The Direct Support Professional also participates in quarterly review meetings.
This is an excerpt from our ODP Directives: The Regulation Revisions Related to the Individual Support Plan (ISP) Webinar, Part 3 ¿ Clarifications and updates 2011, page 6, which states in paragraph 5:
¿A program specialist from each licensed provider are the only members of the ISP team that must be present at the Initial, Annual Update, and Revision ISP meetings¿¿
Also on page 10, which states in paragraphs 3 and 4;
¿The direct service worker is an important member of the ISP team and must be sent an invitation to the ISP meeting. The direct service worker contributes information to the ISP Annual Review Meeting, but is not required to attend.¿¿ ¿The only person required to attend the ISP meetings is the program specialist.¿ |
07/07/2017
| Implemented |
| 2390.156(a) | The following individual ISP reviews were completed late: Individual #5 January-March 2017 completed 4/26/2017; October-December 2016 completed 1/24/2017; July-September 2016 completed 10/28/2016; April-June 2016 completed 7/29/2016. Individual #8 January-February (only two months) completed 3/29/2017; September-December 2016 completed 1/10/2017; June-August 2016 completed 9/28/2016. Individual #6 October-December 2016 completed 1/23/2017; July-September 2016 completed 10/24/2016; April-June 2016 completed 7/18/2016. Individual #9 July-September 2016 completed 10/26/2016. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | Individual # 6 had meetings scheduled past the ¿90 day rule¿ as indicated by the Licensing Team
Individual # 8 had meetings scheduled past the 90 day rule as well.
Our past interpretation of the Regulation 156(a)had been based on the LII Explanation which indicated that ¿The three month period starts from the date of the last review, therefore 4 reviews over the course of one year is the minimum standard.¿ We have scheduled our meetings within the month it was being held, as close to the date as possible to keep from losing the Annual Review Update Date schedule as required by ODP.
Beginning October 1, 2017, new Policy and Procedure will indicate that scheduling of all ISP Reviews should always occur prior to the end a 3 month period starting from the date of the last review as indicated in the LII. This may mean that the full plan team may not be available, but that as long as the required team members and the individual can meet, a meeting will be held within the 3 month period. All Program Specialists will be trained in the new procedure.
Individual # 5 had a re-schedule notice in the file indicating a team conflict of schedule making the meeting 2 days past the 90 day rule.
Individual # 9 had a re-schedule notice in the file indicating a team conflict of schedule making the meeting 12 days past the 90 day rule.
Our current policy is:
When the team schedules an ISP review date, it is originally agreed upon by all members of the plan team. However, occasions arise where a member has a conflict and a re-scheduling notice is sent to all plan team members and is filed for documentation.
Beginning October 1, 2017, new Policy and Procedure will indicate that rescheduling should always occur prior to the end of the 3 month period, unless there is documentation of an emergency. This may mean that the full plan team may not be available, but that as long as the required team members and the individual can meet, a meeting will be held within the 3 month period. All Program Specialists will be trained in the new procedure. |
10/02/2017
| Implemented |
| 2390.156(c)(1) | Individual #9 ISP outcome, Focus on Work 60% of the time, ended 10/26/2016. ISP review 1/19/2017 reviewed this outcome for the entire month of October 2016 and also reviewed a new outcome in November 2016; however the new outcome actually began October 27, 2016. | The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter. | Program Specialist failed to capture 2 days of data for the ISP Outcome goal at the end of October when transitioning to a new goal. This is within our current Policy and Procedure and was an error on the part of the staff. All Program Specialists were retrained on appropriately measuring and documenting goals on the ISP Review as well as ending and beginning new ISP Outcome goals. Retraining occurred on August 11, 2017. |
08/11/2017
| Implemented |
| 2390.156(c)(2) | Individual #2 behavioral support plan was not reviewed on the ISP review 5/16/2017. Individual #11 behavioral support plan not reviewed on ISP reviews 4/3/2017 and 10/5/2016. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Individual #2 Behavior Support Plan was not reviewed during the ISP Review on 5/16/2017.
Individual #11 Behavior Support Plan was not reviewed on 4/3/2017 and 10/5/2016 during the ISP Review.
Reviewing and documenting the review of the Behavior Plans is within our current Policy and Procedure for all individuals served who have a BSP. All Program Specialists were retrained on the procedure including the review and documentation of the review of the Behavior Support Plan in the ISP Review meeting. Retraining occurred on August 4, 2017.
Further, as part of what we anticipate is improved compliance, beginning October 1, 2017 the ISP Review Form will be updated. That update will include all applicable sections of the ISP specific to the facility as regulated by 156(c)(2). |
08/04/2017
| Implemented |