| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.16 | Individual #1 has a restrictive procedure plan. According to that plan, only a Modified Bridge Restraint which is defined as a c-clamp to his/her right arm is approved for staff to use as a restrictive technique. According to his/her 5/24/17 documented restraint incident report, Staff #3 held Individual #1's legs which was not an approved restraint.
- Individual #1's ISP indicates he/she has a seizure protocol that needs followed. His/Her seizure protocol indicated to call 911 if seizures last more than 5 minutes or a cluster of seizures lasting longer than 15 minutes. On 11/9/17 and 9/6/17 staff documented on a seizure chart', times that Individual #1 was having seizures. On the 11/9/17 seizure chart, seizures were documented as such: 8:50 (2), 8:51, 8:54, 8:55, 8:59, 9:01, 9:06, 9:07, 9:10, 9:11 (2), 9:14, 9:16, 9:20. On the 9/6/17 seizure chart, seizures were documented as such: 1:04, 1:05, 1:06, 1:07, 1:10, 1:12, 1:13, 1:13, 1:16, 1:16, 1:16, 1:17, 1:17, 1:17, 1:18, 1:19, 1:20, 30 sec, 30 sec, 30 sec, 30 sec, 30 sec, 1:23 30 sec, 1:25 30 sec, 1:26 30 sec. There is no documentation that 911 was called after the first cluster of seizures on either day. Individual #1's record indicated he/she had a seizure on 4/19/17 however the facility did not have documentation of the seizure. The program specialist's notes indicate Individual #1 had a seizure, the program specialist called (residential) staff and will send incident report (IR) home in Individual #1's lunch box.
-Individual #1's ISP indicates he/she is to have food cut into dime sized pieces. During the facility's onsite inspection on 11/29/17, licensing staff witnessed day program staff giving Individual #1 a lunchables meal on a plate. The lunchables meal contained pieces of lunch meat, pieces of cheese and crackers approximately the size of a dollar coin. The size of the lunchables meal contents were not altered from its original packaged size. According to the facility's internal incident reporting system, an incident report was created on 3/31/17 indicating that on 3/29/17 Individual #1 was being fed lunch and he/she was choking and his/her face was flushed. According to Individual #1's weekly/monthly documentation, staff recorded that on 3/30/17 Individual #1 wasn't feeling himself/herself, ate very little for lunch- fruit cup and a little sweet potatoes and water. The incident report that was completed on 3/31/17 indicated that upon completion of the incident report, it will be scanned and sent to Individual #1's residential team. This was days after the facility indicated that Individual #1 choked on his/her food, then continued to not eat well and wasn't feeling himself/herself' the day after. Upon review of some emails between Individual #1's residential facility, day program facility and his/her supports coordinator, Individual #1's entire team was not aware of the 3/29/17 choking incident until the time frame 3/31/17 to 4/4/17. | This applies to abuse occurring at the facility.
Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse.
Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview
| This applies to abuse occurring at the facility. All staff who works directly with individual #1 were retrained on the seizure protocol (dated 4/24/17) and how to complete a seizure chart. The program specialist was retrained in keeping and filing all seizure documentation in the respective files for each seizure. All staff was trained in seizure disorders and how to document seizures using the seizure report form. The program specialist received an updated seizure protocol for individual #1 on 2/14/18; all staff were immediately trained in the updates to the seizure protocol which included a clear definition of what a seizure looks like for individual #1 and when to contact 911. The facility director retrained all staff in incident reporting, making a special note to document the time that 911 was dialed and the time that the emergency services personnel arrived to the center. The incident report is to be submitted immediately to the facility director. The facility director will contact the Quality Enhancement Director to report the incident and a HCSIS report will be filed. The program specialist is responsible for collecting, maintaining, and filing all documentation for individual #1¿s seizure activity. All program specialists were retrained in maintaining records for individuals. All program files of individuals who have a seizure disorder will be reviewed for thoroughness and updated, as needed. |
06/29/2018
| Implemented |
| 2380.17(d)(1) | Staff #4 indicated on the facility's unusual incident report form that on 5/24/17 Individual #1 was restrained for 2.5 minutes using a c-clamp restraint, 3 minutes but did not indicate the type of restraint used, restrained by staff holding Individual #1's legs so he/she wouldn't kick,' and also restrained Individual #1 three other times throughout the incident on 5/24/17. On 9/26/17 staff documented on a daily note that two, 30 second c-clamp restraints were used on Individual #1 for a total of 1 minute. The agency did not notify the county mental health and intellectual disabilities program, the funding agency, or the regional office of the department of the documented restraints used on Individual #1 on 5/24/17. | The facility shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department, within 72 hours after an unusual incident occurs, to: The county mental health and intellectual disability program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or intellectual disability. | The facility shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department, within 72 hours after an unusual incident occurs, to: The county mental health and intellectual disability program of the county to which the facility is located if the individual involved in the unusual incident has mental illness or intellectual disability. The incident for individual #1 dated 5/24/17 and 9/26/17 was reported to Montgomery county¿s MH/IDD and an investigation was conducted a certified investigator from the agency, and an investigator from Montgomery County. All program specialists were retrained in unusual incidents (what it is, what qualifies, what is the protocol), including planned or emergency restraints. Any time a restraint occurs (planned or unplanned), the staff shall immediately report the incident to the facility director and/or assistant director who will alert the Quality Enhancement Director, or designee to input the incident into HCSIS. The RPP for individual #1 was revised to include the type of restraint that is approved for use, the duration, date, time, and the staff who implemented the restraint. All staff has been trained in the updates that were made to individual #1¿s RPP. |
06/29/2018
| Implemented |
| 2380.19 | On 11/9/17 and 9/6/17 staff documented on a seizure chart', times that Individual #1 was having seizures. On the 11/9/17 seizure chart, seizures were documented as such: 8:50 (2), 8:51, 8:54, 8:55, 8:59, 9:01, 9:06, 9:07, 9:10, 9:11 (2), 9:14, 9:16, 9:20. On the 9/6/17 seizure chart, seizures were documented as such: 1:04, 1:05, 1:06, 1:07, 1:10, 1:12, 1:13, 1:13, 1:16, 1:16, 1:16, 1:17, 1:17, 1:17, 1:18, 1:19, 1:20, 30 sec, 30 sec, 30 sec, 30 sec, 30 sec, 1:23 30 sec, 1:25 30 sec, 1:26 30 sec. There is no record of the length of each seizure or any information regarding the type of seizure and behaviors before, during and after the seizure. Individual #1's record indicated he/she had a seizure on 4/19/17 however the facility did not have documentation of the seizure. The program specialist's notes indicate Individual #1 had a seizure, the program specialist called (residential) staff and will send incident report (IR) home in Individual #1's lunch box. | The facility shall maintain a record of an individual's illnesses, traumas and injuries requiring medical treatment but not inpatient hospitalization, and seizures that occur at the facility or while under the supervision of the facility. | The facility shall maintain a record of an individual¿s illnesses, traumas and injuries requiring medical treatment but not inpatient hospitalization, and seizures that occur at the facility or while under the supervision of the facility. All staff who works directly with individual #1 were retrained on 11/30/17 on the protocol to completing a seizure chart, and reporting all seizures to individual #1¿s program specialist/or the facility director. All staff (direct service professionals, program coordinators, program specialist, and the assistant director) was trained by the facility director in the protocol to reporting and documenting all seizures that occur at the facility. Staff received training on how to fill out a seizure chart. The program specialists were retrained in keeping the records, documenting seizure activity in the individual¿s file, and contacting the individual¿s family/residential/family living provider. File reviews will be conducted on a quarterly basis by the facility director/assistant director to ensure all criteria has been met for compliance. |
06/29/2018
| Implemented |
| 2380.33(b)(18) | Staff working with Individual #3 never received training from a certified medical professional on administering medications rectally or feedings via g-tube. Individual #3 is fed via g-tube daily and is prescribed two as needed rectal medication for his/her seizures. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | The program specialist shall be responsible for the following: Coordinating the training or direct service workers in the content of health and safety needs relevant to each individual. The program specialist scheduled training with individual #3¿s nurse to retrain all staff that provides direct care to individual #3. The training was completed on 1/24/18. Training topics included how to feed individual #3 via the g-tube and how to administer the PRN rectal seizure medication. All staff present signed off on the training sheet. All program specialists were retrained on having signature sheets for all trainings. They were retrained in the requirements in coordinating trainings for all direct service workers in the content of health and safety needs relevant to each individual within 30 days of the receipt of this plan. This training will part of the program specialist training handbook and reviewed annually by the Facility Director with current program specialists and new program specialists. The Assistant Director and/or the Facility Director will conduct quarterly file reviews to ensure compliance in accordance to training completed in the content of health and safety needs for each individual. All training signature sheets will be collected and stored as proof of all health and safety needs trainings. |
06/29/2018
| Implemented |
| 2380.58(a) | The lower window screen on the window on the right side of the building was ripped almost the whole way across. The bike seat on the stationary bike in the older adult room had approximately a 6'-12' rip across the seat. | Floors, walls, ceilings and other surfaces shall be in good repair. | The floors, walls, ceilings, and other surfaces shall be in good repair for the licensed facility. The Facility Director communicated with the maintenance department (on 2/2/18) to schedule maintenance for the lower window screen to be replaced, and for the stationary bike located in the older adult room to be thrown away. The maintenance department scheduled a repair for the cited items in accordance to 2380.58(a). The designated safety committee team member will complete monthly site inspections which includes a check list. The designated team member will document and report any hazards to DEC¿s safety committee during the monthly meetings. The facility director will review the site inspections and communicate to the maintenance department of any potential safety hazards that need to be repaired. All staff (program specialists, program coordinators, direct service professionals, and assistant facility director) will be trained on DEC¿s monthly site inspection checklist. All staff will be retrained in reporting safety hazards (floors, walls, ceilings, and other surfaces). The Facility Director, Assistant Facility Director, and the Program Specialists will monitor for hazards (floors, walls, ceilings, and other surfaces) daily as they monitor the program. DEC¿s safety¿s committee collects and tracks all reported hazards and reviews them during monthly meetings. |
06/29/2018
| Implemented |
| 2380.69(e) | The bathroom in the older adult room was not equipped with soap or paper towels. The bathroom did not have a sink either and no way to sanitize hands after using the bathroom. | Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer. | Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or an air hand dryer. The bathroom in the older adult room has been equipped with soap and paper towels. A maintenance request and bid has been submitted and accepted to renovate the bathroom to install a fully functioning sink. The sink is estimated to be installed by the end of May 2018. Until the renovation is complete; staff will monitor the bathroom, daily, checking that there is soap and paper towels in bathroom at all times. All staff will be trained in the regulations to meet compliance as stated in 2380.69(e). The janitor will be responsible for replenishing/restocking all of the bathrooms, daily, with soap and paper towels; they will initial a check-list that will be hanging on the wall to monitor daily. The check-list will be turned into the facility director on a weekly basis. |
06/29/2018
| Implemented |
| 2380.83(a) | The written emergency evacuation procedure did not include the means of transportation in the event of an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. The emergency evacuation procedures were updated by the Facility Director on 2/2/18 to include the means of transportation in the event of an emergency. All staff will be retrained in the emergency evacuation procedure to review staff responsibilities, means of transportation, emergency shelter location, and an evacuation diagram specifying directions for egress in the event of an emergency by the facility director. All staff will review the responsibilities of the individuals, with the individuals, in the event of an emergency; the individuals will be able to respond appropriately with staff support. The Facility Director or the Assistant Director will review the procedure annually to ensure the procedure is up to date with the appropriate information. If the procedure needs to be updated sooner, the Facility Director will update and retrain all staff as needed. The procedures are hanging throughout the building and a copy is kept in a file located in the Facility Director¿s office. |
06/29/2018
| Implemented |
| 2380.87(b) | Individual #4 is deaf and nonverbal and the fire alarm system was not equipped so that he/she would be alerted in the event of a fire. During the onsite fire drill on 11/29/17, the strobe lights attached to the fire system in the main program area were not bright enough to alert someone in the event of a fire. | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. A tactile signaler was ordered and received to use for individual #4. DEC¿s maintenance director installed the transmitter that connects to the fire alarm system and transmits to the device which will be triggered to vibrate and light-up to alert individual #4 that the fire alarm has been activated. The maintenance director also adjusted the strobe light on the alarm station. All staff has been trained in how the device works. Staff will work with individual #4 to help him adjust to wearing the device on a daily basis while at the center. Staff have documented concerns which will be addressed, as they arise, to ensure individual #4 is safe at all times. A review of the evacuation procedures in the event of a fire/fire drill was also conducted for staff. The program specialist and the facility director will track progress made in the effectiveness of how the device functions for individual #4 during monthly fire drills. Changes and training will occur on an as needed basis by the program specialist and/or facility director to maintain compliance as per 2380.87(b). |
06/29/2018
| Implemented |
| 2380.111(a) | Individual #3 had a physical examination completed on 10/28/16 and not again until 11/20/17, outside of the annual time frame. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. The facility director provided retraining in the requirements for individual¿s physical examination with all program specialists. The program specialists will keep track of the individual¿s physicals and will maintain appropriate documentation in their attempts to receive a copy of the physical examination within the 12 month time frame prior to admission, and annually thereafter. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking the date on annual physicals and documenting when they are not in compliance. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.111(c)(3) | Individual #1's 4/27/17 physical examination document did not include a current tetanus (tdap) booster. The physical indicated the tdap was last completed in 2002. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical examination shall include: immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual #1¿s Lifetime Medical History included her Tetanus booster (Adacel) was received on 4/9/13. The program specialists were retrained in the regulation requirements as they are explained under 2380.111(c)(3). The program specialists will check all physicals to ensure they meet compliance. If there is information missing from the physical, the program specialist shall document all attempts to communicate with the individual¿s team to rectify the missing information. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking that all immunization records on annual physicals have been filled out. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.111(c)(8) | Individual #1's 4/27/17 physical examination document indicated no' for physical limitations. However he/she is wheelchair bound, cannot bare weight, and has emergency guards/braces on at all times. | The physical examination shall include: Physical limitations of the individual. | The physical examination shall include: physical limitations of the individual. The program specialists will check all physicals to ensure they meet compliance. A note has been added to individual #1¿s file with the program specialist¿s initials stating individual #1¿s physical limitations. If there is information missing from the physical, the program specialist shall document all attempts to communicate with the individual¿s team to rectify the missing information. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking that all physical limitations are documented, as appropriate, on annual physicals. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.111(c)(9) | Individual #2's 8/29/17 physical examination document did not include his/her allergies. This section of the physical examination document was left blank. According to Individual #2's Individual Support Plan (ISP) h/she has seasonal allergies. | The physical examination shall include: Allergies or contraindicated medication. | The physical examination shall include: Allergies or contraindicated medication. The program specialist made a note to individual #2¿s physical documenting seasonal allergies. If there is information missing from the physical, the program specialist shall document all attempts to communicate with the individual¿s team to rectify the missing information. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking that all allergies or contraindicated medication are documented, as appropriate, on annual physicals. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.111(c)(10) | Individual #1's 4/27/17 physical examination document indicated none' for information pertinent to diagnosis and treatment in case of an emergency. However he/she is diagnosed with seizures that are increasingly getting worse, Cerebral Palsy, he/she is non-verbal and has very aggressive behaviors towards himself/herself and others that require occasional restraints. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The program specialist made a note to individual #1¿s file indicating additional pertinent information that must be included on the physical examination form. If there is information missing from the physical, the program specialist shall document all attempts to communicate with the individual¿s team to rectify the missing information. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking that all medical information pertinent to diagnosis and treatment in case of an emergency are documented, as appropriate, on annual physicals. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.111(c)(11) | Individual #3's 11/20/17 physical examination document indicated under recommended diet and special instructions as tolerated' however he/she is fed via G-tube. | The physical examination shall include: Special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual¿s diet. The program specialist made a note to individual #3¿s file documenting fed via G-tube under recommended diet and special instructions as `part of the physical examination. If there is information missing from the physical, the program specialist shall document all attempts to communicate with the individual¿s team to rectify the missing information. The facility director and/or the assistant director will conduct file reviews on a quarterly basis which will include checking that all special instructions for an individual¿s diet are documented, as appropriate, on annual physicals. All files will be reviewed and updated accordingly to meet compliance. The respective program specialist will be responsible for documenting their attempt to receive an updated copy to maintain compliance. |
06/29/2018
| Implemented |
| 2380.115(2) | The emergency medical plan did not include the method of transportation to be used for an emergency medical situation. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used and the emergency staffing plan to be used for an emergency medical situation. The emergency medical plan was updated on 12/1/17 to include the method of transportation to be used for an emergency medical situation, in addition to the emergency staffing plan. The facility director reviewed the updated plan with all staff to make them aware of the transportation and staffing methods that shall be implemented in the event of an emergency medical situation. The emergency medical plan has hung on the front bulletin board in the main hallway, and a copy has been placed inside the licensing book that is kept secured in the facility director¿s office. The emergency medical plan will be reviewed and updated, as needed, on an annual basis. The facility director will maintain and implement the emergency plan as it is written. In the event of the facility director¿s absence, the assistant director will be back-up to updating and implementing the emergency medical plan as it is written. The facility director will review the emergency medical plan with all staff as part of the annual training. |
06/29/2018
| Implemented |
| 2380.115(3) | The emergency medical plan did not include an emergency staffing plan to be used for an emergency medical situation. | The facility shall have a written emergency medical plan listing the following: An emergency staffing plan. | The facility shall have a written emergency medical plan listing the following: The method of transportation to be used and the emergency staffing plan to be used for an emergency medical situation. The emergency medical plan was updated on 12/1/17 to include the method of transportation to be used for an emergency medical situation, in addition to the emergency staffing plan. The facility director reviewed the updated plan with all staff to make them aware of the transportation and staffing methods that shall be implemented in the event of an emergency medical situation. The emergency medical plan has hung on the front bulletin board in the main hallway, and a copy has been placed inside the licensing book that is kept secured in the facility director¿s office. The emergency medical plan will be reviewed and updated, as needed, on an annual basis. The facility director will maintain and implement the emergency plan as it is written. In the event of the facility director¿s absence, the assistant director will be back-up to updating and implementing the emergency medical plan as it is written. The facility director will review the emergency medical plan with all staff as part of the annual training. |
06/29/2018
| Implemented |
| 2380.124(a) | Staff #1 administered medications to Individual #1 on numerous days in September and October 2017; 10/23/17, 10/20/17, 10/16/17, 10/12/17, 10/8/17 and 9/21/17 for example. Staff #1 did not sign the medication log to indicate who administered the medication on those days. Staff #1's initials were next to the administration spot. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | A medication log listing the medications prescribed, dosage, time, and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Staff #1 was removed from the list of medication administrators. All staff that is trained for medication administration were retrained with an overview of the requirements needed to sign a MAR, including their signature and date as stated in 2380.124(a). The facility director and/or another practicum observer or medication trainer will review the MARS on a monthly basis. Staff retraining will occur on an as needed basis. |
06/29/2018
| Implemented |
| 2380.128(a) | Medication Trainer, Staff #2, provided a certification pass date of 9/11/17 on Staff #1 initial medication administration training practicum. However, Staff #1's initial medication administration practicum summary indicated Staff #1 only scored a 39 out of 50 points possible on the multiple choice test which is not a passing score. According to the medication administration training course, staff must pass the multiple choice examination test with a 40 or above in order to pass that section or complete remediation if a passing score is not met. According to the facility director, Staff #1 did not take the online remediation course to increase her score to a passing score. Information was only reviewed with Staff #1 via phone with Staff #2 to increase her score to 41. Staff #1 has administered medication to Individual #1 on 9/21/17, 10/8/17, 10/12/17, 10/16/17, 10/20/17, 10/23/17, etc. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical, and eye and ear drop prescription medications. Staff #1 was immediately pulled from the list of medication administrators. If staff #1 would like to administer medications, they would need to take the medication administration course again, and pass the test with at least a score of 40. A meeting was held on 4/30/18 with DEC¿s staff training and program support coordinator, two medication practicum observers/trainers, and the instructor of Melmark¿s medication administration class. It was agreed that all tests with the scores shall be submitted by Melmark¿s instructor to the respective Director confirming a passing score of 40 or above. Once a score of 40 or above has been obtained, the facility director or designee will conduct the observation practicum. Upon successful completion of the practicum, the staff will be added to the medication administration list. All tests and training dates will be kept secure in the facility director¿s office. |
06/29/2018
| Implemented |
| 2380.155(a) | Individuals' lunches for the day are kept locked in the refrigerator in the large program room. Individuals do not have restrictive procedure plans to have their lunches locked.
-On 5/24/17, Staff #3 and #4 documented on a handwritten incident log that Staff #3 helped with holding Individual #1's legs so he/she wouldn't kick.' Individual #1's restrictive procedure plan did not indicate this was an approved restraint that could be used. Individual #1's restrictive procedure plan had an implementation date of 2/16/17 but was not approved by the human rights committee until 4/18/17. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures. The lock was removed from the refrigerator in the large program room on 12/1/17. The individuals at the center have access to their lunches, anytime, throughout the day. All staff was trained on 11/10/17 in restrictive procedures, training included examples and an explanation of what is considered restrictive and what is not restrictive; all staff was retrained by the agency¿s training and program support coordinator on 2/13/18. Staff was given training on what they should do in the event of them witnessing or performing a restrictive procedure during the program day. Staff should immediately report the incident to the facility director. In the absence of the director, the incident should be reported to the assistant facility director. Any time a restrictive procedure is used, the staff who has witnessed the procedure will be responsible for reporting it immediately and filling out the incident report in the appropriate timeframe. The incident will be submitted to the appropriate program specialist who will contact the agency¿s Quality Enhancement (QE) Director to report the use of a restrictive procedure. The program specialist will provide a copy of the report to the facility director who will enter the incident into EIM. The QE director shall act as the backup in the event that the facility director is not available to submit the initial report to EIM. The program specialist will report the incident to the individual¿s team, and will provide a copy of the report, as it is requested by team members. The final report will be filed and kept as part of the individual¿s record. |
06/29/2018
| Implemented |
| 2380.155(d) | Individual #1's restrictive procedure plan was not signed and dated by the chairperson and program specialist for the 10/18/17 restrictive procedure committee meeting. The restrictive procedure committee chairperson did not date Individual #1's restrictive procedure plan for the 4/18/17 review meeting.
Individual #1's ISP indicates he/she has a seizure protocol that needs followed. His/Her seizure protocol indicated to call 911 if seizures last more than 5 minutes or a cluster of seizures lasting longer than 15 minutes. On 11/9/17 and 9/6/17 staff documented on a seizure chart', times that Individual #1 was having seizures. On the 11/9/17 seizure chart, seizures were documented as such: 8:50 (2), 8:51, 8:54, 8:55, 8:59, 9:01, 9:06, 9:07, 9:10, 9:11 (2), 9:14, 9:16, 9:20. On the 9/6/17 seizure chart, seizures were documented as such: 1:04, 1:05, 1:06, 1:07, 1:10, 1:12, 1:13, 1:13, 1:16, 1:16, 1:16, 1:17, 1:17, 1:17, 1:18, 1:19, 1:20, 30 sec, 30 sec, 30 sec, 30 sec, 30 sec, 1:23 30 sec, 1:25 30 sec, 1:26 30 sec. There is no documentation that 911 was called after the first cluster of seizures on either day.
Individual #1's ISP indicates he/she is to have food cut into dime sized pieces. During the facility's onsite inspection on 11/29/17, licensing staff witnessed day program staff giving Individual #1 a lunchables meal on a plate. The lunchables meal contained pieces of lunch meat, pieces of cheese and crackers approximately the size of a dollar coin. The size of the lunchable meal contents were not altered from its original packaged size.
Individual #2's ISP updated 10/30/17 indicates he/she is working on an outcome of community integration. The ISP indicates he/she will participate in various activities at day program including music, sensory, food prep, community outings and team games. His/Her weekly and monthly documentation from 9/25/17 to 11/10/17 indicated no community outing offered' on each sheet for this entire time period. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. | The restrictive procedure plan shall be reviewed, approved, signed, and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months. Individual #1¿s RPP was revised to include a signature/date line for the program specialist and chairperson. The program specialist and the chairperson will sign anytime the plan is revised, or at least every 6 months. The RPP was revised on 12/1/17. It was submitted, and approved by the Peer Review Committee on 1/22/18. The program specialist and the chairperson signed and dated the updated plan on 1/22/18. All regulations under 2380.155(d) have been reviewed by the chairperson and program specialist to maintain compliance on all RPP in place. At the conclusion of all PRC meetings, the program specialist will be responsible for getting the appropriate signatures and dates prior to filing the RPP in individual #1¿s file. All files containing a RPP will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.155(e)(4) | Individual #1's Restrictive Procedure Plan (RPP) indicated that an incident form will be completed when the seated on the floor basket-hold restraint is used. However the plan does not indicate the circumstances under which that restraint can be used, how to use the restraint, etc. Individual #1's RPP also indicated exclusion may not be used more than 4 times within a 24 hour period and may not exceed a total of 60 minutes in any two hour period. However the plan did not include what exclusion entailed and the circumstances under which the procedures may be used. | The restrictive procedure plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | The restrictive procedure plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. The RPP for individual #1 was updated on 12/1/17. The updated included a detailed description of the type of restrictive procedure that may be used and the appropriate circumstances that notes when the procedure should be implemented. Any information that was not specified for individual #1, was removed from the plan. The updated RPP was submitted, reviewed, and approved by the Peer Review Committee on 1/22/18. All staff who work directly with individual #1 were trained on 11/30/17 in the RPP. All staff will be trained in the RPP by the program specialist. The program specialist was retrained in the requirements for writing a RPP as it is stated in 2380.155(e)(4). All files containing a RPP will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.155(f) | Individual #1's Restrictive Procedure Plan (RPP) indicated that daily data tracking of his/her behaviors was to occur. According to the facility director, staff did not track Individual #1's daily behaviors and would use tracking logs when Individual #1 had an incident that required a restraint or incident report to be entered. | The restrictive procedure plan shall be implemented as written. | The restrictive procedure plan shall be implemented as written. Individual #1¿s daily behavior tracking form was presented to the two staff who works directly with her on a daily basis. They were retrained in how to complete this form which included a description of individual #1¿s target behaviors as they are defined in her RPP; training occurred on 11/30/17. All staff at the center will be trained in how to fill out the daily tracking form for individual #1¿s behavior as per her RPP. The program specialist collects the daily tracking forms as documentation. The program specialist will retrain all staff, as needed, to maintain compliance. |
06/29/2018
| Implemented |
| 2380.156(a) | Staff #4 and #5 applied restraints to Individual #1 multiple times throughout the year, an example was an incident that occurred on 5/24/17, and neither Staff #4 or #5 received training in the use of and ethics of using restrictive procedures including the use of alternate positive approaches within the past 12 months. The last training regarding this topic occurred over 10 years ago for Staff #5. | If a restrictive procedure is used, at least one staff person shall be available when the restrictive procedure is used who has completed training within the past 12 months in the use of and ethics of using restrictive procedures including the use of alternate positive approaches. | If a restrictive procedure is used, at least one staff person shall be available when the restrictive procedure is used who has completed training within the past 12 months in the use and ethics of using restrictive procedures including the use of alternate positive approaches. All staff has been retrained in the use of restrictive procedures, positive approaches, safety mechanics, staff effectiveness and ethics, incident report writing, and preventing abuse, neglect, and exploitation. New staff receives positive approaches training during their new hire orientation that is conducted by the agency¿s training and program support coordinator. The facility director monitors and coordinates with the agency¿s training and program support coordinator annual training for all staff on the use of and ethics of using restrictive procedures. Training records will be reviewed on a bi-annual basis, or as needed, by the facility director and/or assistant facility director to maintain compliance of all trainings related to the use of restrictive procedures and positive approaches. |
06/29/2018
| Implemented |
| 2380.165 | Multiple restraints were used on Individual #1 on 5/24/17 according to documentation in his/her record completed by Staff #4. However the time each restrictive procedure was used, the duration of the restrictive procedures, the methods of intervention used to address the behavior, the behaviors addressed and the specific procedures followed was not documented for all interventions during the incident on 5/24/17. Staff #4 completed a handwritten restraint incident report for Individual #1 on 5/24/17 and a typed restraint incident report of the same incident on 5/25/17. The 5/24/17 handwritten restraint incident only indicated Staff #3 held Individual #1's legs at some point during the incident, Staff #4 held Individual #1's arm in a c-clamp restraint three times, then Staff #5 held Individual #1's arm for 3 minutes and again held Individual #1's arm in a c-clamp for 2.5 minutes. The report does not indicate the staff members who applied the restraints. It only indicates initials or first names.
-Individual #1's weekly documentation indicated that many other restraints were used throughout the year, however none were documented to include the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure. The following are examples of restrictive procedures that were not documented; from 5/22/17-5/26/17 staff documented 4 c' clamp restraints, from 9/18/17-9/22/17 staff documented 1 c' clamp restraint and 2 c' clamp modified restraints, from 9/25/17-9/29/17 staff documented 1 c' clamp restraint and 2 c' clamp modified restraints, and from 10/2/17-10/6/17 staff documented 1 c' clamp restraint and 2 c' clamp modified restraints. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, and the individual¿s condition following the removal of the restrictive procedure shall be kept in the individual¿s record. All staff has been retrained in the use of restrictive procedures, positive approaches, safety mechanics, staff effectiveness and ethics, incident report writing, and preventing abuse, neglect, and exploitation. A new form was created on 2/8/18 to include a more detailed description to meet the requirements as stated in 2380.165; staff was trained in how to fill this form out; this form is to be completed daily. The program specialist reviewed, revised, and presented the written restrictive procedure plan to all staff. Any time a restrictive procedure is used, the staff who has implemented the plan will be responsible for reporting it immediately and filling out the incident report in the appropriate timeframe. The incident will be submitted to the appropriate program specialist who will contact the agency¿s Quality Enhancement (QE) Director to report the use of a restrictive procedure. The program specialist will provide a copy of the report to the facility director who will enter the incident into EIM. The QE director shall act as the backup in the event that the facility director is not available to submit the initial report to EIM. The program specialist will report the incident to the individual¿s team, and will provide a copy of the report, as it is requested by team members. The final report will be filed and kept as part of the individual¿s record. |
06/29/2018
| Implemented |
| 2380.173(1)(ii) | Individual #3's record did not indicate identifying marks. His/Her record indicated his/her identifying marks was he/she wears sunglasses'. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | Each individual¿s record must include the following information: personal information including: The race, height, weight, color of hair, color of eyes, and identifying marks. Individual #3¿s personal information sheet was updated to include identifying marks to reflect that she wears sunglasses. All program specialists have been re-trained by the facility director in the requirements needed to be included on an individual¿s personal information sheet; this training included what type of things should be documented as identifying marks (i.e. birth marks, scars, glasses, etc.) All new program specialists and staff will be trained in the requirements as stated in 2380.173(1)(ii). The direct service professionals will be trained, by the facility director, to review the personal information sheets for accuracy when they review the files for the annual update. The Program Specialists will review the personal information form annually, and update information as needed. If the individual has a change in personal information prior to his/her annual update, the program specialist will update the personal information sheet to reflect the update. The facility director/assistant facility director will complete quarterly file reviews. The reviews will include the personal information sheet; if a change is needed, the reviewer will document the changes needed and the respective program specialist will update the file accordingly. All individual files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.173(1)(v) | Individual #1's dated photograph in his/her record was dated 4/12', over 5 years old. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Each individual's record must include the following information: Personal information including: A current, dated photograph. Individual #1¿s picture was taken in December 2017; the updated picture has been placed into their file. All program specialists have been retrained in the requirements for individual¿s records that include the explanation that an individual¿s photograph is current as long as the photograph still looks like the individual. An individual¿s photograph may need to be taken each year, or every five years. All direct service professionals have been trained by the program specialists to look at each individual¿s photograph when they review files for annual updates to make note of the date and reference if the picture is still an accurate image of the individual. File reviews will be completed on a quarterly basis by the facility director and/or the assistant facility director. If an individual¿s photograph needs to be updated, the program specialist will be responsible for taking a new picture (using the center¿s camera), printing, dating, and filing the updated picture in the individual¿s file. All new program specialists will be trained in all licensing requirements as they pertain to the individual¿s records. All individual files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.173(9) | Individual #1's 4/27/17 physical indicated he/she had no know allergies. His/Her Individual Support Plan (ISP) indicated he/she takes Benadryl as needed for allergies. Individual #1's ISP indicated he/she needs a two person assist to walk however it also indicates he/she can't bare weight. His/Her ISP indicated his/her seizures are controlled by his/her medications. However he/she has been hospitalized multiple times in 2017 due to many cluster seizures.
-Individual #3's 11/20/17 physical examination document indicated under contraindicated medications: penicillin and Cipro. However his/her 10/28/19 physical and ISP indicate that he/she is allergic to red food dye #3, penicillin, Cipro and amoxicillin. His/Her supervision level in his/her ISP indicated he/she required a 1:3 staff to individual ratio while at day program. His/her 8/15/17assessment indicated he/she receives a staffing ratio of 1:2-1:6 while at program. His/Her identification sheet in his/her record indicated he/she receives a 1:3 staffing ratio at the program. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under 2380.186. Individual #1¿s team met on 2/15/18 to discuss all of the content discrepancies that were stated in the ISP and on the physical. A note to the file has been made by the program specialist correcting all of the discrepancies and the ISP shall be updated accordingly. The program specialists have been retrained in the requirements regarding content discrepancies in all paperwork including the physical to update the ISP in the annual update or revision. File reviews will be conducted on a quarterly basis by the facility director and/or the assistant director. Any content discrepancies will be reported to the respective program specialist who is responsible for sending an e-mail to the team in order to hold a meeting to correct all discrepancies. All files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.176(a) | Individuals' records were left unlocked and accessible throughout the facility when they were not in use. Record information included outcomes, daily notes, allergies, protocols and personal information. This information was unlocked in binders sitting on shelves, desks and tables throughout the facility. Individuals' first name and allergy information was posted on a pole in the middle of the large program room. | Individual records shall be kept locked when they are unattended. | Individual records shall be kept locked when they are unattended. All of the individual records that include outcomes, daily notes, allergy information, protocols, and other personal information has been removed from all program areas and placed into the program specialist¿s office, temporarily, until locking file cabinets are purchased and received for each program group. All files are kept locked in the program specialist¿s office. Staff has been provided with notebooks where they can keep daily notes secure throughout the day. The quick medical reference was removed from the middle of the program room. Each program area has a copy of the quick medical guide that is kept out of sight, in a more secure location for staff to easily access. The facility director retrained all staff (direct service professionals, program coordinators, program specialists, and the assistant director) in keeping all individual records locked/secure when they are unattended. All staff was instructed to be mindful as they move throughout the center on a daily basis; if they find information left unattended, they should give it to their supervisor. The facility director, assistant director, and/or program specialists will conduct a monthly walkthrough to ensure all staff is in compliance. Staff will be retrained, as needed, to ensure compliance is met. |
06/29/2018
| Implemented |
| 2380.181(c) | Individual #2's 11/22/17 assessment did not indicate that the assessment was based on assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. Individual #2's assessment was revised on 1/31/18 to include all of the requirements stated under code 181(1). A new assessment guide has been created to assist in the thoroughness of completing an assessment. The facility director retrained all program specialists in the requirements needed for the content that must be included in an individual¿s assessment as per licensing regulations. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(d) | Individual #1's 1/25/17 assessment, Individual #2's 11/22/17 assessment and Individual #3's 8/15/17 assessment was not dated by the program specialist. The date was prepopulated and the computer system used to generate the assessment was not a secure system. | The program specialist shall sign and date the assessment. | The program specialist shall sign and date the assessment. Individual #1¿s assessment dated 1/25/17, was updated and sent out to the team on 1/19/18 with the program specialist¿s signature and hand written date. Individual #2's assessment dated 11/22/17, was updated with the program specialists signature and hand written date on 1/31/18; the team received a copy of the amended assessment. Individual #3's assessment was updated with the program specialist's signature and handwritten date; the amended assessment was sent to the team on 2/1/18. The facility director retrained all program specialists in the requirements needed for the content that must be included in an individual's assessment as per licensing regulations. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(3)(iii) | Individual #1's 1/25/17 assessment did not include his/her current level of personal adjustment skills. The assessment indicated he/she may have a tantrum' but did not indicate what a tantrum was or how it manifested in relation to personal adjustment skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | The assessment must include the following information: the individual's current level of performance and progress in the following areas: personal adjustment. The amended assessment included what a tantrum looks like and the potential factors that may trigger or cause individual #1 to have a tantrum (181.e.3.iii). The facility director retrained all program specialists in the requirements needed for the content that must be included in an individual¿s assessment as per licensing regulations. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(4) | Individual #1's 1/25/17 assessment did not include his/her level of supervision needed in the community. His/Her assessment indicated he/she required 1:3 staff to individual supervision ratio while at the facility and within arms-reach when he/she was sitting down. Individual #1 sits in his/her wheelchair all day. According to the director of the facility, all individuals have a 1:6 supervision level at the program.
-Individual #3's 8/15/17assessment did not indicate his/her supervision needs. His/Her assessment indicated his/her staffing ratio is 1:2-1:6, which is appropriate at the training center. Individual #1 while in the community <25% with a W5950 remains appropriate.'
-Individual #2's 11/22/17 assessment did not include his/her supervision needs at the facility. His/Her assessment indicated that his/her current ratio meets his/her needs which is a 1:2-1:6 while in the building. While in the community he/she is a 1:2-1:3 ratio and needs to be in reach (arms-length) while out.' | The assessment must include the following information: The individual¿s need for supervision. | The assessment must include the following information: The individual¿s need for supervision. Individual #1¿s levels of supervision needs were updated to include both her needs for the facility and the community (181.e.4); Individual #2¿s assessment was updated levels of supervision needs were updated to include both her needs for the facility and the community (181.e.4); Individual #3¿s levels of supervision needs were updated to include both her needs for the facility and the community (181.e.4). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(6) | Individual #1's 1/25/17 assessment didn't include his/her ability to use or avoid poisonous materials. His/Her assessment only indicated that he/she hasn't attempted to ingest any poisonous materials. His/Her Individual Support Plan (ISP) indicated he/she is unable to distinguish poisonous materials or handle them appropriately.
-Individual #3's 8/15/17 assessment does not indicate his/her ability to use and avoid poisons. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Individual #1¿s and #3¿s assessments were updated to reflect their ability to use or avoid poisonous materials (181.e.6). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(7) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 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. | 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 degrees Fahrenheit and are not insulated. Individual #1 and #3¿s assessments were amended to include their knowledge of heat sources and ability to move away (181.e.7). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(10) | - Individual #1's 1/25/17 assessment did not include a lifetime medical history nor was one sent to team members. Individual #1's lifetime medical history wasn't created until 2/14/17 by his/her residential provider. Individual #3's 8/15/17 assessment did not include his/her lifetime medical history. The assessment indicated the lifetime medical history was attached to the assessment however the lifetime medical history behind the assessment was revised on 9/27/17. | The assessment must include the following information: A lifetime medical history. | The assessment must include the following information: A lifetime medical history. A lifetime medical history was completed and attached to individual #1 and #3¿s assessment (181.e.10). All program specialists were retrained in the requirements for lifetime medical histories. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(12) | Individual #1's 1/25/17 assessment does not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment. His/Her assessment only indicated activities he/she likes to do, not what the agency was recommending for services, training, etc. Individual #3's 8/15/17 assessment and Individual #2's 11/22/17 assessment does not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment as well. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Recommendations for specific areas of training, vocational programming and competitive community-integrated employment was added to individual #1, #2, and #3¿s assessment (181.e.12). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual #1's 1/25/17 assessment did not include progress over the last 365 days in health. The 2017 and 2016 assessments were also verbatim from each other. | 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 information: The individual¿s progress over the last 365 calendar days and current level in the following areas: health. A review of individual #1¿s progress over the last 365 days in the following areas was added to her amended assessment: health (181.e.13.i). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 assessment did not include progress over the last 365 days in motor and communication skills. The 2017 and 2016 assessments were also verbatim from each other. | 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: The individual¿s progress over the last 365 calendar days and current level in the following areas: motor and communication skills. Individual #1 and #3¿s assessments were amended to include their progress over the last 365 calendar days and current level in the areas of motor and communication skills. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 assessment did not include progress over the last 365 days in personal adjustment. The 2017 and 2016 assessments were also verbatim from each other. | 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 information: the individual¿s progress over the last 365 calendar days and current level in the following areas: personal adjustment. Individual #1 and #3¿s assessments were amended to include their progress over the last 365 calendar days and current level in the area of personal adjustment. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 assessment did not include progress over the last 365 days in socialization. The 2017 and 2016 assessments were also verbatim from each other. | 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 information: The individual¿s progress over the last 365 calendar days and current level in the following areas: socialization. Individual #1 and #3¿s assessments were amended to include their progress over the last 365 calendar days and current level in the area of socialization. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 assessment did not include progress over the last 365 days in recreation. The 2017 and 2016 assessments were also verbatim from each other. | 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. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days in the following areas: recreation. Individual #1 and #3¿s assessments were amended to include their progress over the last 365 calendar days and current level in the area of recreation. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 1/25/17 assessment and Individual #3's 8/15/17 assessment did not include progress over the last 365 days in community integration. The 2017 and 2016 assessments were also verbatim from each other. | 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. | 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 and #3¿s assessments were amended to include their progress over the last 365 calendar days and current level in the area of community- integration. The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.181(e)(14) | - Individual #3's 8/15/17 assessment did not indicate his/her ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. The program specialist updated the assessment to reflect individual #3¿s ability to swim under their knowledge of water safety and ability to swim (181.e.14). The facility director will train all new program specialists on how to write an assessment and the content that must be included to meet compliance. All direct service professionals were trained by the facility director in conducting annual file reviews. Quarterly file reviews will be completed by the facility director and/or the assistant director. Any assessments that are missing the required information will be documented and reported to the appropriate program specialist to update and resubmit to the team members; the program specialist will also be retrained in all regulations. All program files will be reviewed and updated appropriately to meet compliance as per 2380.181 regulations regarding assessments. |
06/29/2018
| Implemented |
| 2380.183(3) | - Individual #1's Individual Support Plan (ISP) did not include a method for evaluating his/her activity exploration' outcome. | The ISP, including annual updates and revisions under § 2380.186 (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 under 2380.186 (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. An e-mail was sent out to individual #1¿s supports coordinator to request a team meeting be scheduled to discuss conflicting information and missing information that was written the annual ISP. The meeting was held and a critical revision ISP was sent to the team on 4/11/18 with the updated information to reflect the method of evaluation that will be used to determine progress towards the activity exploration outcome. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(5) | Individual #2's Individual Support Plan (ISP) updated 10/30/17 indicates he/she is prescribed psychotropic medications for psychiatric diagnosis. However his/her ISP does not indicate that he/she utilizes a protocol to address his/her social, emotional and environmental needs at day program. The protocol to address behaviors in Individual #2's ISP only indicates his/her behaviors manifest as pushing tables, di.183srobing, attempting to expose himself/herself and requesting a hand slap or a high five. According to his/her behavior tracking sheet, staff are tracking the following behaviors: poking others, grabbing others ie) clothing, pushing tables, pushing/knocking over objects, forceful high five, throwing objects, spitting and a blank category for new behaviors that arise. Additional behaviors that staff have tracked in the blank category are sleeping, getting up and turning around during lunch, tipping chair, touching others things and reaching for electrical socket. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of diagnosed psychiatric illness. The program specialist sent an e-mail on 2/1/18 to individual #2's supports coordinator with the social, emotional, and environmental plan (SEEP) attached; the program specialist requested that the information in the plan be added to the ISP. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(6)(i) | Individual #1's Individual Support Plan (ISP) did not include an assessment to determine the causes or antecedents of his/her behaviors while at day program. His/Her ISP didn't include a restrictive procedure plan (RPP) the day program is to utilize. His/Her ISP indicated he/she had a behavior support plan and it wasn't restrictive. The RPP in his/her ISP also indicated the plan was used at his/her residential facility and it had completely different outcome objectives then the RPP that day program utilizes. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. An e-mail was sent to individual #1¿s supports coordinator on 4/19/17 with the request for a team meeting to discuss the discrepancies and missing information in the ISP. The program specialists requested that the assessment to determine the antecedents of individual #1¿s behavior while at the day program be added to the ISP, in addition to the restrictive procedure plan that has been written and approved for the day program. The restrictive procedure plan was revised, reviewed, and approved by DEC¿s Peer Review Committee; the plan has been distributed to individual #1¿s support team. A critical revision meeting was rescheduled and held on 2/15/18. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(6)(ii) | Individual #1's Individual Support Plan (ISP) did not include a protocol for addressing the underlying causes or antecedents of his/her behaviors while at day program. His/Her ISP didn't include a restrictive procedure plan (RPP) the day program is to utilize. His/Her ISP indicated he/she had a behavior support plan and it wasn't restrictive. The RPP in his/her ISP also indicated the plan was used at his/her residential facility and it had completely different outcome objectives then the RPP that day program utilizes. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. An e-mail was sent to individual #1¿s supports coordinator on 4/19/17 with the request for a team meeting to discuss the discrepancies and missing information in the ISP. The program specialists requested that the assessment to determine the antecedents of individual #1¿s behavior while at the day program be added to the ISP, in addition to the restrictive procedure plan that has been written and approved for the day program. The restrictive procedure plan was revised, reviewed, and approved by DEC¿s Peer Review Committee; the plan has been distributed to individual #1¿s support team. A critical revision meeting was rescheduled and held on 2/15/18. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(6)(iii) | Individual #1's Individual Support Plan (ISP) did not include the method and timeline for eliminating the use of restrictive procedures while at day program. His/Her ISP didn't include a restrictive procedure plan (RPP) the day program is to utilize. His/Her ISP indicated he/she had a behavior support plan and it wasn't restrictive. The RPP in his/her ISP also indicated the plan was used at his/her residential facility and it had completely different outcome objectives then the RPP that day program utilizes. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. The restrictive procedure plan (RPP) was revised and approved by DEC¿s Peer Review Committee. An e-mail was sent to individual #1¿s supports coordinator on 4/19/17 with the request for a team meeting to discuss the discrepancies and missing information in the ISP. The program specialists requested the an assessment to determine the antecedents of individual #1¿s behavior while at the day program be added to the ISP, in addition to the restrictive procedure plan that has been written and approved for the day program. The restrictive procedure plan was revised, reviewed, and approved by DEC¿s Peer Review Committee; the plan has been distributed to individual #1¿s support team. A critical revision meeting was rescheduled and held on 2/15/18. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(6)(iv) | Individual #1's Individual Support Plan (ISP) did not include a protocol for intervention or redirection without utilizing restrictive procedures while at day program. His/Her ISP didn't include a restrictive procedure plan (RPP) the day program is to utilize. His/Her ISP indicated he/she had a behavior support plan and it wasn't restrictive. The RPP in his/her ISP also indicated the plan was used at his/her residential facility and it had completely different outcome objectives then the RPP that day program utilizes. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for intervention or redirection without utilizing restrictive procedures. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. The restrictive procedure plan (RPP) was revised and approved by DEC¿s Peer Review Committee. An e-mail was sent to individual #1¿s supports coordinator on 4/19/17 with the request for a team meeting to discuss the discrepancies and missing information in the ISP. The program specialists requested the an assessment to determine the antecedents of individual #1¿s behavior while at the day program be added to the ISP, in addition to the restrictive procedure plan that has been written and approved for the day program. The restrictive procedure plan was revised, reviewed, and approved by DEC¿s Peer Review Committee; the plan has been distributed to individual #1¿s support team. A critical revision meeting was rescheduled and held on 2/15/18. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(7)(i) | Individual #1's Individual Support Plan (ISP) did not include a protocol for intervention or redirection without utilizing restrictive procedures while at day program. His/Her ISP didn't include a restrictive procedure plan (RPP) the day program is to utilize. His/Her ISP indicated he/she had a behavior support plan and it wasn't restrictive. The RPP in his/her ISP also indicated the plan was used at his/her residential facility and it had completely different outcome objectives then the RPP that day program utilizes. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: vocational programming, community involvement, and competitive community-integrated employment. The Program Specialist updated individual #1¿s assessment on 1/19/18 to include their ability to advance in vocational programming. An e-mail was sent to the team requesting a critical revision team meeting be scheduled to discuss the discrepancies and missing information in the ISP. The team met on 2/15/18 to submit a critical revision ISP. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(7)(ii) | Individuals #1 and #3's Individual Support Plans (ISP) didn't include his/her potential to advance in community involvement. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Community involvement. | The ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: vocational programming, community involvement, and competitive community-integrated employment.Individual #1 and #3's assessments were updated on 1/19/18 and 2/1/18, respectfully, to include their potential to advance in community involvement. The program specialist sent the amended assessments to the respective team members with the request to the supports coordinator to revise the ISP to include each individual¿s potential to advance in community involvement. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.183(7)(iii) | Individuals #1-#3's Individual Support Plans (ISP) didn't include his/her potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (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 ISP, including annual updates and revisions under 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: vocational programming, community involvement, and competitive community-integrated employment. The assessments for individual #1 and #3 were updated on 1/19/18 and 2/1/18, respectfully, to include their potential to advance in competitive community-integrated employment. The program specialist sent the amended assessments to the respective supports coordinators with the request to add this information into their ISP. All program specialists have been retrained in the requirements stated under regulation 2380.183 and 2380.186. Training also included the protocol to follow if there is missing information or a discrepancy in the ISP; the program specialist is responsible for sending an e-mail to the supports coordinator with the requested changes. The facility director/assistant director will conduct file reviews on a quarterly basis. Any files that do not meet the criteria for 2380.183 will be reported to the appropriate program specialist and they will be retrained, as needed. All program files will be reviewed and updated, as needed, to meet compliance. |
06/29/2018
| Implemented |
| 2380.185(b) | Individual #1's 1/25/17 assessment and Individual Support Plan (ISP) indicated he/she required 1:3 staff to individual supervision ratio while at the facility and staff within arms-reach when he/she was sitting down. Individual #1 sits in his/her wheelchair all day. According to the director of the facility, all individuals have a 1:6 supervision level at the program. During the facility's onsite inspection on 11/29/17, licensing staff witnessed day program staff not providing Individual #1 with arm's-length supervision while he/she was seated in his/her wheelchair. | The ISP shall be implemented as written. | The ISP shall be implemented as written. An e-mail was sent out to individual #1¿s supports coordinator with the request to update the supervision section in the ISP regarding individual #1¿s level of supervision and staff ratio at the day program. This e-mail also included a request for a team meeting. A critical revision was completed on 4/11/18; however, the supervision needs were incorrect as per team agreement. Another e-mail was sent by individual #1¿s program specialist requesting that the ISP be updated to match the program assessment as per team agreement and discussion. Individual #1¿s assessment was updated on 1/19/18 to align with the ISP. The facility director retrained all individual #1¿s direct staff on her supervision needs as per her program assessment and team discussion. Individual #1¿s program assessment was updated to match the team discussion. All program specialists were retrained on the requirements stated until 2380.185(b); training included the protocol to be implemented when there is conflicting information presented in an individual¿s ISP. All staff will be trained to review the individual¿s assessment and ISP for implementation and accuracy, annually. File reviews will be completed on a quarterly basis by the facility director/assistant facility director. The program specialists, assistant director, and the facility director monitor the program throughout the day to ensure all staffing ratios are appropriate as per the individual ISP. All program files will be reviewed for accuracy as per 185(b) to maintain compliance. |
06/29/2018
| Implemented |
| 2380.186(b) | Individuals #1's and #3's Individual Support Plan (ISP) reviews were not dated by the program specialist. The date was prepopulated. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. All of the ISP reviews for individuals #1 and #3 were corrected (signed and dated) by the program specialist. The facility director retrained all program specialists on 11/29/17 in all regulations regarding ISP reviews. The training reviewed that all ISP reviews need to be signed and dated; there shall not be any prepopulated dates on any forms. All new program specialists will be trained in the regulations that include completing ISP reviews. The facility director and/or the assistant facility director will complete file reviews on a quarterly basis. They will check that all ISP reviews have been signed and dated by the individual and the program specialist. If a date or signature is missing; the facility director and/or assistant facility director will report the missing information to the respective program specialist, in addition to retraining on the requirements as per chapter 2380.186(b). The program specialist will correct the document(s). All direct service professionals will be trained to look for handwritten signatures and dates as they review files for annual updates. |
06/29/2018
| Implemented |
| 2380.186(c)(1) | Individual #3's ISP reviews completed on 12/30/16, 3/30/17, 6/30/17 and 9/29/17 did not include progress and participation on his outcome of socialization. Individual #1's reviews don't include participation and progress on activities outcome. | 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 facility licensed under this chapter. | 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 facility licensed under this chapter. 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 reviews for individual #3 were updated and corrected to include a summary of the participation and progress that was made towards his ISP outcome related to socialization. The program specialist for individual #3 updated the ISP reviews to include his supervision needs in the community and his community participation/involvement during each review period. The ISP reviews for individual #1 were updated and corrected to include her participation and progress made towards her activities outcome. The program specialist updated and corrected individual #1¿s ISP reviews to include a review of her seizures, restrictive behavior plan, restrictive behaviors, and her community involvement/participation. The facility director retrained all program specialists on 11/29/17 in all regulations regarding ISP reviews. The training reviewed that all ISP reviews need to include the following: a review of monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. The reviews must also include a review of each section of the ISP specific to the facility licensed under this chapter. All new program specialists will be trained in the regulations that include completing ISP reviews. The facility director and/or the assistant facility director will complete file reviews on a quarterly basis. These file reviews will include reading the ISP reviews to ensure they include a summary of all of the individual¿s participation and progress on their ISP outcomes, in addition to a review of each section of the ISP specific to the facility licensed under this chapter. The facility director and/or assistant facility director will report the missing information to the respective program specialist, in addition to retraining on the requirements as per chapter 2380.186(c)(1)(2). The program specialist will correct all document(s). All direct service professionals and program coordinators have been trained/retrained by individual #1¿s program specialist on how to complete the daily documentation for individual #1¿s seizure and behavior chart. This training also included signs/symptoms for identifying when individual#1 is having a seizure and what her identified behaviors are; staff reviewed individual #1¿s restrictive behavior plan. The program specialist reviews individual #1¿s daily documentation on a monthly basis. Staff report individual #1¿s behaviors and seizures on a daily basis, or as often as they occur. |
06/29/2018
| Implemented |
| 2380.186(c)(2) | Individual #3's ISP reviews dated 12/30/16, 3/30/17, 6/30/17 and 9/29/2017 did not review his supervision needs and community involvement/participation. Individual #1's ISP reviews do not review her seizures, restrictive behavior plan, restrictive behaviors, or community involvement/participation. | 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 the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. 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 reviews for individual #3 were updated and corrected to include a summary of the participation and progress that was made towards his ISP outcome related to socialization. The program specialist for individual #3 updated the ISP reviews to include his supervision needs in the community and his community participation/involvement during each review period. The ISP reviews for individual #1 were updated and corrected to include her participation and progress made towards her activities outcome. The program specialist updated and corrected individual #1¿s ISP reviews to include a review of her seizures, restrictive behavior plan, restrictive behaviors, and her community involvement/participation. The facility director retrained all program specialists on 11/29/17 in all regulations regarding ISP reviews. The training reviewed that all ISP reviews need to include the following: a review of monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. The reviews must also include a review of each section of the ISP specific to the facility licensed under this chapter. All new program specialists will be trained in the regulations that include completing ISP reviews. The facility director and/or the assistant facility director will complete file reviews on a quarterly basis. These file reviews will include reading the ISP reviews to ensure they include a summary of all of the individual¿s participation and progress on their ISP outcomes, in addition to a review of each section of the ISP specific to the facility licensed under this chapter. The facility director and/or assistant facility director will report the missing information to the respective program specialist, in addition to retraining on the requirements as per chapter 2380.186(c)(1)(2). The program specialist will correct all document(s). All direct service professionals and program coordinators have been trained/retrained by individual #1¿s program specialist on how to complete the daily documentation for individual #1¿s seizure and behavior chart. This training also included signs/symptoms for identifying when individual#1 is having a seizure and what her identified behaviors are; staff reviewed individual #1¿s restrictive behavior plan. The program specialist reviews individual #1¿s daily documentation on a monthly basis. Staff report individual #1¿s behaviors and seizures on a daily basis, or as often as they occur. |
06/29/2018
| Implemented |
| 2380.186(d) | Individuals #1's and #3's Individual Support Plan (ISP) reviews were not sent to plan team members. The reviews did not indicate a date they were sent or to whom. | 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 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. All of the ISP reviews for individual #1 and #3 were sent to the respective plan team members. The program specialist wrote in the names of the team members and the date of when the ISP reviews were sent. All program specialists were retrained by the facility director in the requirements as per code 2380.186(d). All new program specialists will be trained in all of the requirements needed to complete an ISP review by the facility director. Quarterly file reviews will be completed by the facility director and/or the assistant facility director. The reviews will include inspection of all ISP reviews including signatures, dates, and documentation of reviews being sent to the team members. The facility director and/or assistant facility director will report the missing information to the respective program specialist, in addition to retraining on the requirements as per chapter 2380.186(d). All files will be reviewed and updated for compliance. |
06/29/2018
| Implemented |