| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | STAFF #1 DID NOT MEET THE QUALIFICATIONS TO WORK AS A PROGRAM SPECIALIST DURING THE PAST INSPECTION YEAR. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with Intellectual Disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with Intellectual Disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with Intellectual Disability. | Why is the regulation important?
For a Program Specialist, Work experience with individuals with an intellectual disability is essential to enable the Program Specialist to experience the sort of issues that people encounter. The experience helps to develop the Program Specialist in multiple areas that are essential for the role, such as rule and regulations , detailed note taking ability organizational skills knowledge of interventions/plans, helps develop a sense of empathy, the ability to facilitate meetings, active listening skills, critical thinking skills, and verbal and written communication skills
How was the regulation violated?
Program Specialist Molly McGarvey did not meet qualifications of a Program Specialist for 6 months from 12/5/16-6/5/17.
What Caused the Violation?
This regulation was violated due to the an oversight, within the agency during the in house hiring process, Where the regulation was not followed for in house candidates.
What can be done right away to fix the violation?
Molly McGarvey has since met the 2 years work experience working directly with individuals with an intellectual disability, to not be in violation of 6400.44 c(2) on 6/8/17.
What can be done to prevent future violations?
The Agency¿s Job Description for the Program Specialist was revised to reflect the regulation 6400.44c. All future Program Specialist will meet qualifications. See Attachment #2 ¿ Program Director Job Description
Who will be responsible for preventing future violations?
Chief Executive Officer, Tom Kelsch Jr.
Executive Director, Betsy Wendel
Director of Residential Services, Amber Montgomery- Wesley
Director of Services, Tuan Truong |
07/26/2017
| Implemented |
| 6400.64(a) | THERE WERE MULTIPLE BLACK STAINS CONSISTENT WITH DIRT ON THE CARPET IN THE LIVING ROOM NEAR THE COFFEE TABLE. | Clean and sanitary conditions shall be maintained in the home. | Why is the regulation important?
Carpet cleaning can improve the appearance of the home, as well as rid carpeting of trapped pollutants that may contaminate the residence and cause adverse health effects amongst residing individuals. Routine carpet cleaning is important in prevention of everyday dirt, dust, and bacteria.
How was the regulation violated?
Large black stain is located on the living room floor.
What Caused the Violation?
Years of wear/tear from a rocking chair that was used at that location.
What can be done right away to fix the violation?
Thorough vacuuming and professional shampooing of carpet to eliminate current surface bacteria and contaminates.
What can be done to prevent future violations?
routine professional shampooing of the carpet will be schedule. Considering replacing carpet in living room area in future.
Who will be responsible for preventing future violations?
Chief Executive Officer,
Tom Kelsch Jr. |
08/01/2017
| Accepted |
| 6400.181(e)(13)(ii) | INDIVIDUAL #1'S ANNUAL ASSESSMENT DATED 07/06/2016 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF COMMUNICATION. | 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. | Why is the regulation important?
This regulation is important to track individual's progression and growth in goal related areas in order to form approaches and new goals for their future, and best serve the individual and their ISP plans.
How was the regulation violated?
Individual #1 2016 annual assessment did not note his progress or current level of motor and communication skills, financial independence, or managing personal property.
What Caused the Violation?
Program Director and Program Support Manager did not note progress or current level on assessment.
What can be done right away to fix the violation?
Individual's assessment for 2017 will be updated to include information related to level of communication skills.
What can be done to prevent future violations?
Master copies of assessment forms used agency wide will be updated to ensure that a section is created to include the discussion the individuals area of communication. (see attachment)
Who will be responsible for preventing future violations?
Program Director, Molly McGarvey |
08/01/2017
| Accepted |
| 6400.181(e)(13)(vii) | INDIVIDUAL #1'S ANNUAL ASSESSMENT DATED 07/06/2016 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF FINANCIAL INDEPENDENCE. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Why is the regulation important?
This regulation is important to track individual's progression and growth in goal related areas in order to form approaches and new goals for their future, and best serve the individual and their ISP plans.
How was the regulation violated?
Individual #1 2016 annual assessment did not note his progress or current level of financial independence.
What Caused the Violation?
Program Director and Program Support Manager did not note progress or current level on assessment.
What can be done right away to fix the violation?
Individual's assessment for 2017 will be updated to include information related to level of financial independence.
What can be done to prevent future violations?
Master copies of assessment forms used agency wide will be updated to ensure that a section is created to include the discussion the individuals area of financial independence. (see attachment)
Who will be responsible for preventing future violations?
Program Director, Molly McGarvey |
08/01/2017
| Accepted |
| 6400.181(e)(13)(viii) | INDIVIDUAL #1'S ANNUAL ASSESSMENT DATED 07/06/2016 DID NOT DOCUMENT PROGRESS AND GROWTH IN THE AREA OF MANAGING PERSONAL PROPERTY. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Why is the regulation important?
This regulation is important to track individual's progression and growth in goal related areas in order to form approaches and new goals for their future, and best serve the individual and their ISP plans.
How was the regulation violated?
Individual #1 2016 annual assessment did not note his progress or current level of managing personal property.
What Caused the Violation?
Program Director and Program Support Manager did not note progress or current level on 2016 assessment.
What can be done right away to fix the violation?
Individual's assessment for 2017 will be updated to include information related to level of managing personal property.
What can be done to prevent future violations?
Master copies of assessment forms used agency wide will be updated to ensure that a section is created to include the discussion the individuals area of managing personal property. (see attachment)
Who will be responsible for preventing future violations?
Program Director, Molly McGarvey |
08/01/2017
| Accepted |
| 6400.185(b) | THERE WERE NO STRATEGIES DEVELOPED TO TRACK PROGRESS TOWARDS INDIVIDUAL #1'S OUTCOME OF COMPANY. | The ISP shall be implemented as written. | Why is the regulation important?
This regulation is important because tracking progress for individuals growth will help serve the individual's future goals and plans better with more information related to the progress of their current goal and will help with areas to focus on.
How was the regulation violated?
No strategies were put into place for staff to follow regarding the individual's outcome related to having company, while completing daily documentation.
What Caused the Violation?
No strategies/plan was written or implemented for staff to follow while writing daily documentation for the individual.
What can be done right away to fix the violation?
Staff will prompt individual #1 to have company over/go out to see company/talk with friends & family on the phone. Staff will document on daily chart if individual had any contact with friends or family that day. Daily company will be totaled at the end of each month.
What can be done to prevent future violations?
Program Director will Implement daily chart to tract the progress of the individual's goal and ensure it is being filled out and totaled monthly. Staff will be trained on the use of the chart in order to help track progress and also note what approaches were used in daily progress documentation
Who will be responsible for this outcome?
Program Director, Molly McGarvey |
08/01/2017
| Accepted |
| 6400.186(b) | INDIVIDUAL #1'S 3 MONTH ISP REVIEW DOCUMENTATION DATED 04/23/2016 - 07/23/2016, 07/23/2016 - 10/23/2016, AND 10/23/2016 - 01/23/2017 WERE NOT DATED BY THE PROGRAM SPECIALIST UPON COMPLETION. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Why is the regulation important?
To document that quarterly reviews were shared with the individual in a timely manner after review was completed.
How was the regulation violated?
No date was indicated on the signature page of quarterly review.
What Caused the Violation?
Program Director did not put date next to signature of 3 of MSD's quarterly review forms. Did not see date section written at the bottom of the page and therefore did not note it.
What can be done right away to fix the violation?
Program director re-reviewed quarterly reviews with individual and added signature and date.
What can be done to prevent future violations?
New master quarterly review signature page was created with date section placed next to signature section in order to prevent individuals and program directors from missing the date section when reviewing quarterlies in the future. New master quately signature page will be used on call forms going forward. Please see attachment #4
Who will be responsible for preventing future violations?
Program Director: Molly McGarvey |
08/01/2017
| Accepted |
| 6400.186(d) | THERE WAS NO DOCUMENTATION INDICATING THAT INDIVIDUAL #1'S 3 MONTH ISP REVIEW DOCUMENTATION WAS SENT TO TEAM MEMBERS. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Why is the regulation important?
This regulation is important so the Supports Coordinator/ other Team are aware of changes in the Consumers needs in order to update individuals ISP plans.
How was the regulation violated?
Quarterly reviews were being send out to all team members via US mail, and there was no documentation that the plans were being sent.
What Caused the Violation?
Clerical staff that was responsible for sending out the reports was not aware that proof of sending was needed.
What can be done right away to fix the violation?
Nothing can be done to rectify the past violations, new reports will no longer be send through the mail starting right away and will follow our new plan.
What can be done to prevent future violations?
The quarterly reports will be scanned into the computer system and quarterlies will be sent via encrypted email to SCO's and team members. Copies of the send emails will be kept as records of proof of sending reports.
Who will be responsible for preventing future violations?
Jennifer Santucci head of Clerical Staff |
08/02/2017
| Accepted |