| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(2) | The program specialist job responsibilities did not list all the regulatory requirements | (b) The program specialist shall be responsible for the following: (2) Providing the assessment as required under § 6400.181(f) (relating to assessment).
| The Program Specialist job responsibilities were updated to reflect all of the regulatory requirements and added to their performance evaluations/job descriptions. On 10/8/2012 Each Program Specialist was retrained in their job responsibilities and signed the updated Job Description Addendum, which noted that they understand the responsibilities. In the future, New Program Specialist will be trained by the Director of Services and/or the Director of Quality Management, and will be required to sign a copy of the job responsiblities document. A copy of this document will be kept in the Program Specialist employee/training file. |
10/08/2012
| Implemented |
| 6400.46(d) | Employee # 2 had 17 hours of training. | (d) Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.
| Employee #2 did have 24 hours of training. At the time of the licensing inspection we were unable to access the College of Direct Support (CDS) transcripts to verify the CDS training. The previous Training Coordinator had just resigned and we were not sure how to access the records. However, we have now accessed the transcripts verifying the CDS training. Copies of the Staff Development page, CDS transcripts, and CPR/FA will be sent to verify the 24 hours of training. Additionally, since this was a problem beyond just one person we developed a Training Process that addresses the issue of printing out Transcripts at the time the training occurs (see Training Process). |
09/26/2012
| Implemented |
| 6400.46(g) | Employee # 3 had fire safety training on 2/1/11. This employees next fire safety training was on 4/2/12. | (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).
| We have developed a new tracking system for those trainings that are time sensitive (see revised Staff Development page). Note that time sensitive trainings (those that are required annually/bi-annually) will be scheduled on an 11 month or 23 month rotation so that we avoid missing the dates. Additionally, there are times that staff is scheduled for their training in a timely manner and they call off or take personal time on the day that training is scheduled. The Training policy has been revised to address this issue as well (see revised Training Policy). |
10/01/2012
| Implemented |
| 6400.62(a) | Poisons were under the sick in bathroom #1 bathroom. | (a) Poisonous materials shall be kept locked or made inaccessible to individuals.
| A shift check has been established where the outgoing shift does a poison sweep and signs off that they are all locked. If it is discovered by the next shift that poisons are not locked, a call will be placed to the administrative staff on call and will be followed up with disciplinary action. (Please see the 5-2 Reportable Situations Policy). Also, direction was added to the Weekly Assignment Form for staff to do the poison sweep at the end of each shift ensuring that all poisons are to be locked. The Weekly Assignment Form is the form that notes each staff's daily tasks and staff sign off that they have accomplished these tasks. The staff responsible for not locking the poisons received a disciplinary memo. |
10/09/2012
| Implemented |
| 6400.181(f) | There was no documentation that the assessment was shared with the team. | (f) 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, 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).
| A new time file/tracking system was developed to ensure timeliness (see Assessment Tracking Chart and CLA/Lifesharing Assessment Tracking Form). All administrative staff were retrained in their Assessment/ISP responsibilities. The Program Specialist job responsibilities were updated to reflect all of the regulatory requirements and added to their performance evaluations/job descriptions. On 10/8/2012 Each Program Specialist was retrained in their job responsibilities and signed the updated Job Description Addendum, which noted that they understand the responsibilities. In the future, New Program Specialist will be trained by the Director of Services and/or the Director of Quality Management, and will be required to sign a copy of the job responsiblities document. A copy of this document will be kept in the Program Specialist employee/training file. |
10/10/2012
| Implemented |
| 6400.186(a) | Indivudual # 1 did not have ISP reviews as required in 10/11, 1/12, and 4/12. Individual # 2 did not have ISp reviews as required in 9/11, 12/11 and 3/12. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential 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.
| A new system including supervisory oversight and clerical tracking was developed to track compliance with the ISP Review process (see CLA/Lifesharing Quarterly Review Tracking Form).An ISP review was completed for the two individuals reviewed (see Quarterly Reviews).Staff were retrained in their responsibilities for the ISP Quarterly Reviews. |
10/01/2012
| Implemented |
| 6400.186(c)(1) | Monthlies did not include progress for outcomes of both individuals. For indiviudal #! monthly review of behaviors was not completed. | (c) The ISP review must include the following:
(1) 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 residential home licensed under this chapter.
| We revised our Monthly Review form to be more clear and specific to include all ISP Outcomes and added a cue to include documentation on behaviors (see revised Monthly Review form).We used the new form to do a review for both individuals reviewed (see Monthly Reviews). Staff were trained in how to write a quality Monthly Review. |
10/01/2012
| Implemented |
| 6400.188(c) | There was no procedure as to how outcomes would be implemented and progress tracked. | (c) The residential home shall provide services to the individual as specified in the individual's ISP.
| We revised our Program Planning Process to include developing written methodologies for ISP Outcomes (see revised Program Planning Process). We developed written methodologies for the individuals reviewed (see ISP Outcome Methodologies). |
10/08/2012
| Implemented |