| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff person A did not have a physical examination within 2 years of one another. The most recent physical was dated 4-29-14 and the prior physical was dated 4-10-12. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | We will continue to inform staff when their physical examinations are due. Additionally, we will suspend staff until they submit a current physical examination form. This will be monitored by Donna Angelucci, Office Manager. See attached memo. The office manager will develop a tracking that will allow the auditing of all staff physicals and the due dates to ensure that all staff are compliant with this regulation. |
01/01/2015
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 6-27-14 did not include progress and growth in the area of recreation. | 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 tool has been revised to include the area of progress and growth in the area of recreation. Individual #1's assessment was updated to include progress and growth in the area of recreation. This will be monitored monthly by Barbara Miodovnik, Program Specialist. The assessments for all residents will be audited to ensure that all of the required elements of the assessment are included within 30 days of receipt of this plan of correction. The Program Specialist will be trained on how to ensure that all resident assessments include progress and growth in all areas for each resident, within 30 days of receipt of this plan of correction. [SW 2.26.15]See attached. |
01/02/2015
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 6-27-14 did not include progress and growth in the area of community intergration. | 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 tool has been revised to include the area of progress and growth in the area of community integration. The assessment for Individual #1 was updated to include progress and growth in the area of community integration. This will be monitored monthly by Barbara Miodovnik. The assessments for all residents will be audited to ensure that all of the required elements of the assessment are included within 30 days of receipt of this plan of correction. The Program Specialist will be trained on how to ensure that all resident assessments include progress and growth in all areas for each resident, within 30 days of receipt of this plan of correction. [SW 2.26.15]See attached. See attached. |
01/02/2015
| Implemented |
| 6400.183(5) | Individual #1 takes medication to treat a psychiatric illness and the record did not include a social, emotional and environmental plan. | The ISP, including annual updates and revisions under § 6400.186 (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. | A plan was developed to address the social, emotional and environmental needs of this individual and forwarded to the team. All individual's social, emotional and environmental plans will be developed and monitored by the program specialist as needed. The Program Specialist will audit all resident records to ensure that any resident that is treated with medication for a psychiatric illness includes a SEEP within 30 days of receipt of this plan of correction. [SW 2.26.25]See attached plan. |
01/02/2015
| Implemented |