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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(a) | Self-Assessment completed on 10/11/18; license expires 06/30/19. | If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. The retraining will include a review of the regulation regarding the self-assessment.
8. The self-assessments will be distributed and partially completed during a Team Meeting scheduled for 2/7/19. The on site assessment portions will be individually completed by Program Specialists throughout the month of February. Completed self-assessments are due to the Program Director on 3/7/19. |
11/21/2018
| Implemented |
| 6500.121(c)(1) | Physical does not include medical history in Individual #1's record. | The physical examination shall include: (1.) A review of previous medical history. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented prior to 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Site Coordinators and Program Specialists are responsible for making sure all information is included on physicals.
8. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.151(f) | Assessment sent to ISP Team 03/01/18 for 03/08/18 ISP meeting. | The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development of the ISP, the annual update, and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.156(a) | ISP ARUD date 05/08/18; next quarterly review (May-July) to be completed 08/08/18, not completed until 09/10/18. | The family living specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the family living home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change, which impacts the services as specified in the current ISP. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
| 6500.156(b) | 156b (May-July) quarterly ISP review signature sheet not dated. | The family living specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 1. Training for all Program Specialists regarding ISP meetings, ISPs and required information, outcomes, annual exam dates, fire safety and neglect/abuse training, physical requirements, personal information, updated photos, SEEN Plans and regulated reports and requirements for the reports (Assessments, ISP Reviews and Track Changes) was completed on 8/2/18. All records (6400, 6500 and 2380) were to be up to date by 9/21/18.
2. All Program Specialists have updated and shared their deadline lists (ISP Implementation, ISP meeting due date, assessment & track changes due date, BSP/SEEN due date and ISP review due dates for 6400, 6500 and 2380) with both the Program Director and Training & Compliance Officer. Completed 7/24/18.
3. All Program Specialists, upon completion of Assessments, ISP reviews and Track Changes, will include those in an encrypted email to the Supports Coordinator and cc both the Program Director and Training & Compliance Officer to monitor completion of reports in a timely manner.
4. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a daily Roll Call at 9am to discuss goals for the day. This was implemented 7/9/18.
5. All Program Specialists, Training & Compliance Officer, Health Care Coordinator and Program Director have a Team Meeting every Thursday at 1pm to complete trainings, review issues with individuals and/or staff, licensing or other information.
6. Individual supervision of all Program Specialists, Training & Compliance Officer and Health Care Coordinator will occur at least once monthly. This is conducted by the Program Director. This was officially implemented 8/31/18. Program Director has individual supervision with the Director of Operations at least once monthly. This was implemented 9/1/17.
7. Retraining of all of the above was originally scheduled for 11/15/18 but due to the weather has been rescheduled for 11/21/18. |
11/21/2018
| Implemented |
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