| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(f) | Staff #1 had fire safety training 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)(10) | Individual #1's 5/17/18 physical form didn't indicate information pertinent to diagnosis and treatment in case of an emergency. The individual has documented severe behaviors and communication impairments that would prevent him/her from cooperation during emergency treatment and/or relaying accurate information in an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | We will update the physical to include information about Individual #1's communication and behavioral impairments under the section information pertinent to diagnosis and treatment in case of an emergency by 12/31/18. We will submit documentation of updates to the physical by 12/31/18. We will review all the records of the other individuals and document on a spread sheet if they were in compliance or needed correction by 01/31/2019. We will submit the spread sheet and any correction by 01/31/2019. We will train the Program Specialist on what to check when a physical is submitted by a provider or family member to assure that physicals are completed and accurate by 01/31/2019. We will submit evidence of this training by 01/31/2019. The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.111(c)(11) | Individual #2's Individual Support Plan (ISP) indicates he/she is a choking risk and staff are supposed to be within 10 feet of Individual #2 while he/she is eating. The individual's ISP indicates that larger food items of ham, steak and chicken breasts should be cut into smaller pieces. Individual #2's 4/18/18 physical form did not include any of the above dietary needs. Individual #2's record indicated that in December 2017 the individual choked on a peanut butter and jelly sandwich while at another day program. Individual #2's current assessment doesn't include any of the above information about dietary concerns. | The physical examination shall include: Special instructions for an individual's diet. | We will update the individual #2's Assessment and Physical to match the dietary needs of being a choking risk and needing to be within 1 feet of the individual while eating and that larger food items need cut into smaller pieces by 12/15/18 We will submit copies of the updates to physical and assessment by 12/31/18. We will review all the records of all the other individuals and document on a spread sheet if they were in compliance or needed correction by 01/31/2019. We will submit the spread sheet and any correction by 01/31/2019. We will train the Program Specialist on making sure to update the physical and assessment as changes occur by 01/31/2019. We will submit a signature sheet as evidence of this training by 01/31/2019. The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.173(9) | Individual #1's 5/17/18 physical form included allergies to dogs, flu vaccine, grass and latex then cat was added on 5/21/18 by the program specialist. The individuals 5/2/17 physical form indicated allergies to dogs, grass, flu vaccine and latex. Individual #1's medication logs at the facility indicated allergies to seasonal (dust/grass), dogs/cats, fexofenadrine hcl, latex and flu vaccine. Individual #1's Individual Support Plan (ISP) did not include his/her allergies to grass and fexofenadrine hcl. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | We will ask for documentation from Individual #1's doctor for actual allergies by 12/15/18. We will update the individual's ISP and Assessment and Physical to match documentation from the doctor by 12/31/18. We will submit documentation from doctor and evidence of updates to physical, ISP and assessment by 12/31/18. We will review all the records of the other individuals and document on a spread sheet if they were in compliance or needed correction by 01/31/2019. We will submit the spread sheet and any correction by 01/31/2019. We will train the Program Specialist on what to check when a physical is submitted by a provider or family member to assure that physicals are completed and accurate by 01/31/2019. We will submit evidence of this training by 01/31/2019. The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.181(b) | Individual #1 required a 1:1 staff that started on 7/2/18 and increased their attendance days from 3 days per week to 4 days per week on 7/2/18. An assessment was not updated to indicated the change of the individual's services/need until 8/7/18. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 2380.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | An addendum to the assessment will be completed for Individual #1 by 12/15/2018. A copy of the addendum will be submitted by 12/15/2018. 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 01/31/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 01/31/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 01/31/2019. We will train the Associate Director and Program Specialist on when assessments need updated by 01/31/2019. We will submit a signature sheet as evidence of this training by 01/31/2019 The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.181(e)(7) | Individual #1's 4/11/18 assessment did not include their knowledge of heat sources. | The assessment must include the following information: The individual¿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. | An addendum to the assessment will be completed for Individual #1 by 12/15/18. A copy of the addendum will be submitted by 12/15/18. 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 01/31/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 01/31/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 01/31/2019. We will train the Associate Director and Program Specialist on including the knowledge of heat sources in assessments by 1/31/19. We will submit the signature sheet as evidence of this training by 1/31/19.The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.181(e)(9) | Individual #2's Individual Support Plan (ISP) indicates he/she is a choking risk and staff are supposed to be within 10 feet of Individual #2 while he/she is eating. The individual's ISP indicates that larger food items of ham, steak and chicken breasts should be cut into smaller pieces. Individual #2's record indicated that in December 2017 the individual choked on a peanut butter and jelly sandwich while at another day program. Individual #2's current 1/11/18 assessment doesn't include any of the above information about dietary concerns and limitations. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | An addendum to the assessment will be completed for Individual #2, to include all dietary concerns and limitations by 12/15/18. A copy of the addendum will be submitted by 12/15/18. 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 01/31/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 01/31/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 01/31/2019. We will train the Associate Director and Program Specialist on including all dietary needs in assessments as they occur by 1/31/19. We will submit a signature sheet as evidence of this training by 1/31/19. We will retrain all staff on Individual #2 dietary needs by 12/15/18. We will submit a signature sheet as evidence of this training 12/15/18. The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.181(e)(13)(i) | Individual #1's 4/11/18 and 8/7/18 assessments do not include their current level of health. The assessments only included the Individual's medications. | 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. | An addendum to the assessment will be completed for Individual #1, to include her current level of health by 12/15/18. A copy of the addendum will be submitted by 12/15/18.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 01/31/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 01/31/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 01/31/2019. We will train the Associate Director and Program Specialist on including the current level of health in the assessment by 1/31/19. We will submit a signature sheet as evidence of this training by 1/31/19.The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |
| 2380.181(f) | Individual #1's 4/11/18 and 8/7/18 assessments were not sent to his/her behavior support person through cornerstone agency. According to the individual's Individual Support Plan (ISP) they have had the behavior support service since at least 7/1/17. | 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). | We will send the assessment to Individual #1 behavior specialist by 12/31/18. We will submit evidence that we sent the assessment by 12/31/18.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 01/31/2019. We will document if the other records were in compliance or needed correction on a spread sheet listing all individuals by 01/31/2019. The spread sheet and any correction to any other individual's assessment will also be submitted by 1/31/19 We will train the Associate Director and Program Specialist on sending assessments to all team members by 1/31/18. We will submit evidence of this training 1/31/18.The Associate Director will review the individual's records quarterly to provide oversight. |
01/31/2019
| Implemented |