| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(a) | The alarm in the basement was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Select Security repaired the alarm on 4/26/18. Attachment #11. Alarms shall continue to be tested during monthly fire drills; House Supervisor is responsible. |
04/26/2018
| Implemented |
| 6400.163(c) | Individual #1's psychiatric medication management appointments on 1/31/18, 11/8/17, 9/6/17, and 2/8/17do not include the medication necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The 3 Associate Directors and Director of Residential Services are adjusting the current medication management form to reflect suggestions from the licensors and to comply with the regulation. The modified form will be completed no later than 5/25/18; Program Specialists will be trained on it on 5/31/18 and implementation will go into effect 6/1/18. A completed form will be submitted no later than 7/1/18. Program Specialists will be responsible for ensuring the form is pre-populated properly prior to the review appointment. |
07/01/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in health. | 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.
| Individual #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in motor and communication 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: Motor and communication skills. | Individual #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Individual #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in personal adjustment. | 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 ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in 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 #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in recreation. | 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 ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Individual #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual #1¿s ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 4/3/18 did not include progress over the last 365 calendar days and current level in community - integration. | 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 ISP dated 3/15/18 did not state the individual¿s progress over the last 365 calendar days and current level in the following areas: (i) Health, (ii) Motor & Communication Skills, (iii) activities of Residential Living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial Independence, (viii) Managing Persona Property, (ix) Community Integration. This individual¿s addendum is in process, to be completed no later than 5/25/18 and will be submitted.
On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 181(e)(13)(i)-(ix) will be reviewed at all programs. Attachment #13. Program Specialists will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director are responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/11/2018
| Implemented |
| 6400.183(7)(iii) | Individual #1's ISP updated 3/15/18 does not state the potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Vocational programming. | The updates to the individual¿s ISP are attached ¿ Attachment #12. On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 183(7)(i), (ii), (iii), (iv) will be reviewed at all programs. Attachment #13. Program Supervisors will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director is responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/07/2018
| Implemented |
| 6400.183(7)(iv) | Individual #1's ISP updated 3/15/18 does not state the potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| The updates to the individual¿s ISP are attached ¿ Attachment #12. On 5/17/18 the Program Specialists will be directed to perform a record review of all individuals in Residential Services to determine if any others are out of compliance and need to be corrected. This is to be completed no later than 6/15/18. A chart will prepared reflecting the status and any corrections will be attached and submitted no later than 6/22/18.
Additionally, at Treatment Team/Monthly Progress meetings, 183(7)(i), (ii), (iii), (iv) will be reviewed at all programs. Attachment #13. Program Supervisors will be trained on 5/31/18; House Supervisors will be trained on 6/7/18. The Program Specialist and/or Associate Director is responsible for ensuring these areas are addressed at each Treatment Team/Monthly Progress meeting and the form completed accordingly. |
06/07/2018
| Implemented |
| 6400.186(c)(1) | Individual #1's ISP reviews did not document the participation and progress during the prior 3 months towards her current ISP outcomes knowing what to expect, going to a salon, and good vibrations. They reviewed the past outcome independence. | The ISP review must include the following: 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. | The incorrect outcomes were replaced with current outcomes; reviewed at today¿s Treatment Team/Monthly Progress Meeting. The Program Specialist and House Supervisor are responsible for ensuring the correct outcomes, based on current ISP, are being reviewed. Attachment #14. |
05/16/2018
| Implemented |