| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Staff #2 was trained on fire safety on 3/31/17 and not again until 4/2/18. | Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f). | The training was scheduled late for all the program staff. Fire Safety Training for the program is scheduled for the coming year on 03/27/2019. All program staff will be trained on the regulations about fire safety training by 01/31/2019. The Director will provide oversight to make sure the training is not scheduled late in the future. |
01/31/2019
| Implemented |
| 2380.111(c)(5) | Individual #2 had a TB with negative results read on 4/8/16 and not again until 6/1/18. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | We will create a tracking chart for physicals and TB tests by 1/31/2019. We will have the Program Specialist submit the tracking chart to the Associate Director monthly. We will submit the new form and the first one the program specialist does by 2/28/2019. We will train the program specialist on the chart and procedure by 2/28/2019. |
02/28/2019
| Implemented |
| 2380.172(b) | Individual #2's physical exam dated 6/29/18 had additional information entered by Staff #3 in the information pertinent to diagnosis and treatment in case of an emergency section. Additional information was signed but not dated by Staff #3. | Entries in an individual¿s record shall be legible, dated and signed by the person making the entry. | Staff #3 will add the date to the physical exam dated 6/29/18 by 1/31/19. Documentation of this will be submitted by 1/31/19. We will review all the records of the other individuals that attend the program to see if this error occurred anywhere else and will correct such errors by 02/28/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 02/28/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 02/28/2019.The associate director and program specialist will be trained that all entries into the record need to be legible dated and initialed by 1/31/19. The signature sheet for this training will be submitted by 1/31/19. The associate director will review the records quarterly. |
02/28/2019
| Implemented |
| 2380.181(e)(5) | Individual #1's annual assessment dated 8/27/2018, and Individual #2's assessment dated 12/3/2018 did not include the ability to self-administer medication. Each assessment stated each individual does not take medication while at the program, however there was no indication of what their abilities are in regards to medication administration. | The assessment must include the following information: The individual¿s ability to self-administer medications. | An addendum to the assessment will be completed for Individual #1 and Individual#2 by 01/15/19. A copy of the addendums will be submitted by 01/15/19. We will review all the records of the other individuals that attend the program to see if this error occurred anywhere else and will correct such errors by 02/28/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 02/28/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 02/28/2019. We will train the Associate Director and Program Specialist on including the knowledge of heat sources in assessments by 2/28/19. We will submit the signature sheet as evidence of this training by 02/81/19.The Associate Director will review the individual's records quarterly to provide oversight. |
02/28/2019
| Implemented |
| 2380.185(b) | Individual #2's seizure protocol indicated the VNS is to be used for seizure activity. According to the seizure log, there were multiple days of documented seizures where the seizure log does not indicate if the VNS magnet was used over the VNS, as stated on the seizure protocol. Date were as follows: 12/3/18 (twice), 11/30/18 (twice), 11/16/18, 10/19/18 (twice), 10/16/18 (twice), 10/11/18 (twice), 10/9/18, 9/21/18, 9/17/18, 9/4/18, 8/30/18 (three times), 8/13/18, 8/10/18 (three times).
Staff documentation indicated that Individual #2 experienced a "1 min. clustered (8 seizures)" on 11/8/18 at 11:14am. There was no indication that 911 was called for the multiple seizures as indicated in her seizure protocol. | The ISP shall be implemented as written. | We will request clarification from individual #2's doctor on the seizure protocol by 12/31/18. We will update the seizure log to include asking staff if they used the VNS magnet by 12/31/18. We will submit doctor's clarification and new form by 1/31/19. We will train staff on documentation of seizures and Individual's seizure protocol with any doctor clarifications by 1/31/19. We will submit the signature sheet from the training by 1/31/19. We will also submit evidence that staff are using the new seizure log by 2/28/19. We will check the records of the other individuals to see if there is similar violations and update their protocols if necessary. We will submit any changes to other individuals seizure logs by 2/28/19. The Program Specialist will review the seizure logs quarterly. |
02/28/2019
| Implemented |