| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.60(d) | The first aid kit did not contain tweezers. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape and scissors. | First aid kits must contain: antiseptic, adhesive bandages, sterile gauze pads, tweezers, tape, and scissors. The first aid kit for 2390 contains (as of 2/16/18) tweezers. |
02/16/2018
| Implemented |
| 2390.82(a) | The written emergency evacuation procedure did not include the Individuals' responsibility in the event of an emergency. | Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas. | The written emergency evacuation must include staff responsibilities, client responsibilities, means of transportation, emergency shelter location, and evacuation diagram. The emergency evacuation plan for the facility licensed in this chapter was updated by the Facility Director to include the individual(s) responsibilities. The responsibilities of the individuals will be to evacuate the facility in the event of an emergency in an orderly and timely manner, as well as, take instruction from their group supervisor. The emergency evacuation plan was updated and staff retrained on the emergency evacuation plan on 2/6/18. The emergency evacuation plan for this facility includes both 2390 and 2380 housed at this facility location (2710 Terwood). |
02/20/2018
| Implemented |
| 2390.103 | The written emergency medical plan did not include the staffing plan during the emergency. | A facility shall have a written emergency medical plan listing the following:(1)The hospital or source of health care that will be used in an emergency. (2) The method of transportation to be used.(3) Written consent from the client, parent or guardian for emergency medical treatment.(4) The staffing plan during the emergency. | A facility must have a written emergency medical plan listing the following: hospital used in an emergency, method of transportation used, written consent, and the staffing plan during an emergency. The facility director updated the emergency medical plan to include the staffing plan during an emergency. This plan was updated by the facility director on 2/2/18 and includes both programs (2380 & 2390) that reside at this facility's location (2710 Terwood). The emergency medical plan for the licensed facility in this chapter was updated by the Facility Director on 2/2/18 to include the following: an emergency staffing plan. |
02/20/2018
| Implemented |
| 2390.112(b)-1 | Individual #5's date of admission was 10/2/17 and there was no documentation to indicate he/she received written information regarding the vocational facility benefits. He/She did not receive written information regarding civil rights until 10/6/17. | Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. | Upon admission, a client must be given written information outlining working hours, benefits, leave policy, civil rights, grievance procedures, and benefits (for vocational facilities). The facility director provided a letter to individual #5 and a copy of the client handbook (on 2/23/18) detailing information in writing including benefits, civil rights, grievance procedures.
Program specialists were trained on 2/20/18 in the area of new client admission and required information to be presented on or at orientation. This included the benefits offered to new client admissions.
All program specialists will be retrained on the requirements of new client admissions and what to is included in new client orientation. This training will occur within 30 days of receipt of this plan. Staff training as well as quarterly file review will occur (to monitor completion). The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.123 | Individual specific information (time in attendance, jobs completed, names, etc) are left unlocked at each floor supervisors desk. | Information in the client records shall be kept confidential. Client records shall be kept locked when unattended. | Information in the client record must be kept confidential The client record must be kept locked when unattended. The individual information (specific to attendance) was re-coded to not contain confidential information (full name). The individual information (specific to jobs completed) will be filed inside the supervisor's binder and locked while unattended. Supervisor floor staff will be trained on 2/26/18 regarding locking away client confidential information while unattended. All staff will be retrained on this requirement related to confidential information with 30 days of receipt of this plan. staff training as well as monthly monitoring will occur by both the facility director and assistant facility director. The facility director and assistant facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.124(10) | individual #5'S Individual Support Plan (ISP) that's available online, was last updated 11/3/17. However the ISP in his/her record indicated it was last updated on 9/29/17, which was prior to his/her date of admission on 10/2/17. | Each client's record must include the following information: A copy of the current ISP. | Each client's record must include the following: copy of the current ISP. The program specialist for individual #5 was trained on 2/20/18 regarding the requirements of a client's record including copies of current ISP. The program specialists printed and filed a copy of the current ISP for individual #5's chart on 2/20/18.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.124(12) | Individual #5's 12/1/17 assessment indicated he/she did not need to follow any special diet, but that he/she was sensitive to gluten, and that he/she had no food allergies. The lifetime medical history attached to his/her assessment indicated that he/she did not have any allergies or sensitivities. His/Her Individual Support Plan (ISP) indicated that he/she has a sensitivity to gluten and that he/she is not allergic to food. The allergy section in his/her ISP read n/a.'
-- Individual #4's 11/10/17 assessment indicated he/she is able to be unsupervised for 15 minutes at day program and his/her staffing ratio was 1:11 at day program and 1:2-1:3 in the community. HisHer Individual Support Plan (ISP) only indicated he/she required a staffing ration of 1:11 at day program.
-- Individual #3's Individual Support Plan (ISP) indicated his/her food should be cut into bite sized pieces and veggies cooked until they are very soft. This information is not included in his/her assessment. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Each client's record must include the following: content discrepancy in the ISP. The program specialist for individual #5 updated (on 2/23/18) his assessment (dated 12/1/17) to include his sensitive to gluten and that he did not have any food allergies. The program specialist reported (on 2/23/18) to individual #5's S.C. discrepancies from the assessment, lifetime medical history, and ISP related to food allergies and sensitivities specific to food with gluten. The program specialist for individual #4 updated his S.C. of the content discrepancy related to his unsupervised time at day program. The program specialist for individual #3 updated his assessment to include accurate and consistent data related to his food prep. Content discrepancy in the area of food prep for individual #3 was communicated with his S.C. by the program specialist (on 2/20/18).
Program Specialists were trained on 2/20/18 on content discrepancy in the ISP and communicating the discrepancy to the supports coordinator (S.C.).
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(4) | Individual #4's 11/10/17 assessment didn't include his/her supervision needs in the community.
-- Individual #3's 1/9/18 assessment did not indicate his/her need for supervision in the day program or the community. His/Her assessment doesn't include his/her need of physical assistance during day program and in the community.
-- Individual #2's 10/7/17 assessment didn't include his/her supervision needs in the community. His/Her Individual Support Plan (ISP) indicated he/she needs arms-length supervision in community due to history of running into traffic. | The assessment must include the following information: The client's need for supervision. | The assessment must include the following: the client's need for supervision. The program specialist for individual #4 updated (on 2/23/18) her assessment (dated 11/10/17) to include her supervision needs in the community. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to indicate his need for supervision in the day program and while in the community. The program specialist for individual #2 updated (on 2/23/18) his assessment (dated 10/7/17) to include his supervision needs in the community. |
02/26/2018
| Implemented |
| 2390.151(e)(9) | Individual #1's 4/13/17 assessment did not include a full list of his/her diagnosis, or include his/her functional and medical limitations. His/Her Individual Support Plan (ISP) also indicated diagnosis of presbyopia, glaucoma, cataracts, retinopathy, hyperglycemia, and mild paralysis in his/her legs. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | The assessment must include the following: documentation of the client's disability, including functional and medical limitations. The program specialist for individual #1 updated (on 2/23/18) her assessment (dated 4/13/17) to include all her diagnoses including functional and medical.
Program specialists were trained on 2/20/18 on assessments including listing all diagnoses.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(10) | Individual #1's 4/13/17 assessment did not include his/her lifetime medical history. The assessment indicated no' for the section is the lifetime medical history attached to the assessment.' Individual #2's lifetime medical history was not completed with his/her 10/7/17 assessment. | The assessment must include the following information: A lifetime medical history. | The assessment must include: a lifetime medical history. The program specialist for individual #1 updated (on 2/23/18) her assessment (dated 4/13/17) to include her lifetime medical. These documents were sent to individual #1's S.C. (on 2/23/18). The program specialist for individual #2 updated (on 2/23/18) his assessment dated (10/7/17) to include his lifetime medical. These documents were sent to his S.C. (on 2/23/18).
Program specialists were trained on 2/20/18 on requirement of lifetime medical history.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(13)(i) | - REPEAT FROM 1/18/17 RENEWAL INSPECTION: Individual #3's 1/9/18 assessment didn't include his/her current level and progress in the area of 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. | The assessment must include the following: current level in the following area(s): health. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to reflect updates on individual #3's health. The assessment was sent to his S.C. in order to update his ISP.
Program specialists were trained on 2/20/18 on requirement components of an annual assessment.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(13(ii) | Individual #1's 4/13/17 assessment, Individual #2's 10/7/17 assessment, Individual #3's 1/9/18 assessment and Individual #4's 11/10/17 assessment did not include his/her progress and growth in motor and communication skills. It was the same as his/her 2016 assessment. Individual #5's 12/1/17 assessment did not include his/her progress and growth in motor 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. | The assessment must include the following information: progress in the areas of: motor skills and communication skills; The program specialist for individual #1 updated (on 2/23/18) her assessment (dated 4/13/17) to include progress and growth in the areas of motor skills and in communication skills. Individual #1 S.C. was provided the updated assessment (on 2/23/18) in order to make updates to her ISP. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to include progress and growth in the areas of motor skills and communication skills. The program specialist for individual #3 fowarded the updated assessment to his S.C. in order to make updates to his ISP. The program specialist for individual #4 updated (on 2/20/18) his assessment (dated 11/10/17) to include progress and growth in the areas of motor skills and communication skills and fowarded the assessment to his S.C. in order to update his ISP. The program specialist for individual #5 updated (on 2/23/18) his assessment (dated 12/1/17) to include progress and growth in the area of motor skills. The amended assessment was fowarded to individual #5's S.C. (on 2/23/18) to make updates to his ISP.
Program specialists were trained on 2/20/18 on required components of an annual assessment.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(13)(iii) | Individual #3's 1/9/18 assessment did not include his/her current level and progress 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. | The assessment must include the following: progress and current level in the following areas: personal adjustment. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to include his current level and progress in the area of personal adjustment.
Program specialists were trained on 2/20/18 on all required components of the annual assessment.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(13(iv) | - Individual #3's 1/9/18 assessment did not include his/her current level and progress 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. | The assessment must include the following: current level and progress in the following areas: socialization. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to include current level and progress in the area of socialization. The amended assessment was fowarded to individual #3's S.C. (on 2/20/18) in order to update his ISP.
Program specialists were trained on 2/20/18 on the required components of an annual assessment.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(e)(13)(v) | Individual #3's 1/9/18 assessment did not include his/her current level and progress in 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. | The assessment must include the following: current level and progress in the following areas: vocational skills. The program specialist for individual #3 updated (on 2/20/18) his assessment (dated 1/9/18) to include current level and progress in the area of vocational skills. The amended assessment was fowarded to individual #3's S.C. (on 2/20/18) in order to update his ISP.
Program specialists were trained on 2/20/18 on the required components of an annual assessment.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.151(f) | Individual #1's Individual Support Plan (ISP) indicated that his/her brother should be sent information and invited to team meetings. His/Her 4/13/17 assessment was not sent to his/her brother. | 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). | The program specialist must provide copies of the assessment to the S.C. and team members at least 30 calendar days prior to the ISP meeting. The program specialist provided copies to individual #1's brother (on 2/23/18).
The program specialist was trained on 2/20/18 regarding provide copies of the assessment report to all team members.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.153(3) | - Individual #1's Individual Support Plan (ISP) did not include services provided to him/her to develop the skills necessary for promotion into a higher level of vocational programming or into competitive community-integrated employment. His/Her ISP outcome was to socialize with others and participate in non-work related activities. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | The ISP including annual updates and revisions must include the following: the current status in relation to the outcome and the method of evaluation used to determine progress towards the outcome. The program specialist for individual #1 updated her ISP reviews (on 2/23/18) to include her current status in relation to her outcome and the methods used to evaluate her progress. The program specialist for individual #1 updated (on 2/23/18) her ISP reviews and communicated to individual #1's S.C. of the needed change in individual #1's ISP related to services provided to develop skills necessary for promotion into a higher level vocational programming or into a competitive employment program/job.
Program specialists were trained on 2/20/18 on ISP reviews and required components.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.153(4) | - Individual #1's Individual Support Plan (ISP) did not include his/her supervision needs. His/Her ISP indicated he/she required a staffing ratio of 1:11-1:15 at day program and 1:2-1:3 in the community. Individual #1 is aging and may need some physical assistance with walking around the day program and community. According to his/her assessment he/she does have up to 15 minutes of alone time at the day program as long as staff know his/her whereabouts.
- Individual #5's ISP did not include his/her supervision needs. His/Her ISP indicated he/she required a staffing ratio of 1:11-1:15 at day program and 1:2-1:3 in the community. His/Her 12/1/17 assessment indicated that staff need to check to make sure he/she has gotten to his/her destination within the day program when he/she transitions between rooms.
-Individual #3's ISP only indicated he/she required a staffing ratio of 1:2-1:3 in the community. According to his/her 1/9/18 assessment he/she requires physical assistance to walk and verbally notified of surface changes so he/she does not fall. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence. | The ISP including annual updates and revisions must include the following: a protocol and schedule of periods of time the client can be without direct supervision. The ISP must include supervision needs. The program specialist for individual #1 updated her assessment (on 2/23/18) and communicated to her S.C. her supervision needs and staffing ratio in the day program and in the community. The program specialist for individual #5 updated (on 2/23/18) his assessment and communicated with his S.C. regarding his supervision needs and staffing ratio in the day program and in the community. The program specialist for individual #3 updated (on 2/20/18) his assessment and communicate with his S.C. regarding his supervision needs and staffing ration in the day program and in the community.
Program Specialists were trained on 2/20/18 regarding supervision needs and staffing ratios (both in the facility and while out in the community). Program specialists were trained on 2/20/18 on the required elements of annual assessments.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.153(5) | - Individual #5's Individual Support Plan (ISP) did not include his/her protocol to address his/her social, emotional and environmental needs. He/She is prescribed medication for anxiety. The behavior support plan included in his/her ISP indicated it was for school and written in 2014.
-Individual #4's ISP did not include a protocol to address his/her social, emotional and environmental needs. He/She is prescribed medications for hallucinations.
-Individual #2's ISP didn't include a protocol to address his/her social, emotional and environmental needs. He/She is prescribed medications for anxiety. | 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. | A protocol (social, emotional and environmental needs plan) is required for a client if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The program specialist for individual #5 updated (on 2/23/18) his social, emotional and environmental needs plan and fowarded the updates to individual #5's S.C. in order to update the ISP. The program specialist for individual #4 updated (on 2/20/18) his social, emotional and environmental needs plan and fowarded the updates to individual #4's S.C. for updates to individual #4's ISP to be made. The program specialist for individual #2 updated (on 2/23/18) his social, emotional and environmental needs plan and fowarded the updates to individual #2's S.C. in order for updates to be made to his ISP.
Program specialists were trained on 2/20/18 on when a social, emotional and environmental needs plan is required for clients.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.153(7)(i) | Individual #1's Individual Support Plan (ISP) did not include his/her 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. | The ISP including annual updates and revisions must include: an assessment of the client's potential to advance in the following: vocational programming. The program specialist for individual #1 updated (on 2/23/18) her assessment (in the area of potential to advance in vocational programming. The program specialist sent the updated assessment (on 2/23/18) to individual #1's S.C. in order to update the ISP.
Program specialists were trained on 2/20/18 on assessing a client's potential to advance in vocational programming and to include this assessment in the client's annual assessment report in order to update the ISP.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.153(7)(ii) | Individuals #1 and #3's Individual Support Plans (ISP) did not include his/her 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. | The ISP including annual updates and revisions must include: an assessment of the client's potential to advance in the following: community-integrated and competitive employment. The program specialist for individual #1 updated (on 2/23/18) her assessment to include her ability to advance in competitive community-integrated employment and fowarded this assessment to individual #1's S.C. in order for updates to be made to the ISP. The program specialist for individual #3 updated his assessment to include his ability to advance in competitive community-integrated employment and fowarded this assessment to his S.C. in order for updates to be made to individual #3's ISP.
Program specialists were trained on 2/20/18 on ISP and annual assessments required components.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.155(b) | Individual #1's Individual Support Plan (ISP) indicated his/her outcome was to socialize and interact with others during group activities. His/Her ISP reviews documented that he/she was working on an outcome to work in order to make money.
-Individual #5's ISP outcome earn money' indicated he/she was going to focus on his/her job, perform work in a timely manner, accept jobs and complete other jobs when available. The outcome being reviews on his/her ISP review indicates he/she will work to make money and only documented the amount of money he/she was making.
-Individual #3 was assessed to not be safe around poisonous materials. Antiseptics that contained the label to contact poison control office if ingested were left unlocked and accessible in the first aid kit. | The ISP shall be implemented as written. | The ISP must be implemented as written. The ISP reviews were updated for individual #1 and individual #3 to review and document progress on their specific outcomes. The program specialist for individual #1 updated (2/23/18) her ISP reviews to document progress and participation towards her outcome related to socializing and interaction with others. The program specialist for individual #5 updated (2/23/18) his ISP reviews to document progress toward his outcome of earning money.
Individual #3 was assessed to not be safe around poisonous materials. Upon verbal review of citation on 2390.155.b, the facility director ordered lock boxes (on 1/30/18) to lock antiseptics that contained poison control within the 2390 first aide kit. Poisonous materials (eye wash and antiseptic) shall be kept locked within the first aid kit in the first aid room. The Facility Director ordered (on 1/30/18) a locked box to store the eye wash and antiseptic (items that contained labels to contact poison control). The Facility Director trained safety committee staff on citation 2390.155.b. related to first aide items containing labels to contact poison control shall be locked and made inaccessible to individuals in 2390 program that are assessed to be unsafe around poisonous materials; training occurred on 1/26/18.
Program specialists were trained on 2/20/18 on ISP reviews and required components.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.156(c)(1) | Individual #4's Individual Support Plan (ISP) reviews did not review his/her participation and progress with his/her work outcome.
- Individual #3's ISP reviews didn't include a review of his/her participation and progress with his/her employment skills outcome.
- Individual #2's ISP reviews didn't include a review of his/her participation and progress with his/her meaningful day program/employment outcome.
- Individual #5's ISP reviews didn't include a review of his/her participation and progress with his/her work outcome. | 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. | The ISP review must include the following: participation and progress towards the ISP outcome. The ISP review was updated to include the following: review of participation and progress toward the ISP outcomes supported by the services provided by the facility licensed under this chapter. The Program Specialist updated (on 2/20/18) Individual #4's ISP reviews to reflect participation and progress toward's his work outcome. The Program Specialist updated (2/20/18) individual #3's ISP reviews to reflect participation and progress towards his employment skills outcome. The Program Specialist updated (2/23/18) individual #2's ISP reviews to reflect participation and progress towards his meaningful day program/employment outcome. The Program Specialist updated (2/23/18) individual #5's ISP reviews to reflect participation and progress towards his work outcome.
Program Specialists were trained on 2/20/18 on ISP reviews and required components.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.156(c)(2) | Individual #1's Individual Support Plan (ISP) reviews did not review his/her community participation or if he/she experienced any seizures while at program.
- Individual #5's ISP reviews did not review his/her social, emotional and environmental needs plan, behaviors or community integration.
- Individual #4's ISP reviews did not review his/her social, emotional and environmental needs plan.
- Individual #3's ISP reviews did not review his/her social, emotional and environmental needs plan or behaviors that occurred during the previous 3 months. His/Her monthly documentation for May and April 2017 indicated he/she experiences anxiety at program however the 4/28/17 and 7/28/17 reviews indicated he/she did not have any behavioral problems at program. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The ISP review must include the following: a review of each section of the ISP. The ISP review was updated to include the following: review of community participation and occurrences of seizures for individual #1, review of social, emotion and environmental needs for individuals #5, #4, and #3, and a review of behavioral problems including anxiety for individual #5 and #3. The Program Specialist for individual #1 updated (2/23/18) her ISP reviews to review her community participation and occurrences of seizures. The program specialist for individual #5 updated (2/23/18) his ISP reviews to review his social, emotional and environmental needs, review his behaviors, and review of his community participation. The program specialist for individual #4 updated (2/20/18) his ISP reviews to review his social emotional and environment needs plan. The program specialist for individual #3 updated (2/20/18) his ISP reviews to review his social, emotional and environmental needs plan. Updates to individual #3's ISP reviews included review of his behaviors and anxiety while at the day program. The program specialist for individual #3 updated ISP reviews dated 4/28/17 and 7/28/17 on 2/28/18 to reflect required information including: social, emotional and environmental needs plan and behaviors exhibited while at the day program.
Program specialist were trained on 2/20/18 on ISP review and required components.
All program specialist will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.156(d) | Individual #1's Individual Support Plan (ISP) indicated that information should be sent to his/her brother and he should be invited to meetings. Individual #1's ISP reviews were not sent to her brother.
-Individual #5's 11/2/17 ISP review was not sent to his/her SC or family. His/Her 11/22/17 ISP review was not sent to anyone; no documentation of a date sent. | The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The program specialist must provide copies of ISP reviews, including recommendations, to the S.C. and all team members within 30 calendar days after the ISP meeting.
The program specialist for individual #1 sent out (2/23/18) copies of all reports (annual, ISP reviews, and monthly reports) to individual #1's brother.
The program specialist for individual #5 sent out (2/23/18) copies of all ISP reviews to individual #4's S.C. and family.
Program Specialists were trained on 2/20/18 on required distribution of ISP reviews.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |
| 2390.156(e) | Individual #1's Individual Support Plan (ISP) indicated that information should be sent to his/her brother and he should be invited to meetings. Individual #1's brother was never offered the option to decline Individual #1's ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The program specialist must notify team members of the option to decline ISP reviews documentation. The program specialist for individual #1 sent out (2/23/18) copies of all ISP reviews to individual #1's brother. The program specialist contacted individual #1's brother (2/23/18) and offered the option to decline ISP reviews documentation for individual #1.
Program Specialists were trained on 2/20/18 regarding the notification and option to decline ISP review documentation to team members. The training included the process and required form.
All program specialists will be retrained on the requirements of client charts and associated reports within 30 days of receipt of this plan. Staff training as well as quarterly file reviews will occur. The facility director will oversee and monitor this process of correction (2017-18). |
02/26/2018
| Implemented |