Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The self-assessment for the home was completed on 8/17/15; the agency's current certificate of compliance is from 9/1/15 to 9/1/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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.
| The Office Coordinator has an event scheduled in her Outlook calendar starting in March where she can send out the self-assessments that will then be due by April 31. The ID/D Manager will track when they are received to ensure they are completed in a timely manner. |
03/26/2016
| Implemented |
6400.106 | The furnace was inspected on 9/17/14 and then again on 10/28/15. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Office Coordinator set up a tracking spreadsheet to ensure the Facilities Department schedules furnace inspections in a timely manner. The tracking will be monitored by the Office Coordinator and Secretary and the scheduling will be sent out to the Facilities department 1 month ahead of the due date. [Immediately, the ID/D Manager will develop, implement, train staff and oversee a procedures to ensure all furnaces at all community homes are inspected and cleaned at least annually by a professional furnace cleaning company, procedures shall include a review of the written documentation and a system to ensure written documentation of the inspection and cleaning is kept and available for review and tracking. (AS 4/20/16)] |
03/26/2016
| Implemented |
6400.186(a) | Compliance was unable to be measured due to the date of the ISP review being reviewed with Individual #1 was not documented. The electronic signature of the Program Specialist for the 3 month reviews ending 2/17/15 and 5/17/15 were dated 6/10/15 and for the 3 month reviews ending 8/17/15 and 11/17/15 were dated 12/31/15. | 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 date line has been added to MYCS 3 month ISP Review after the individual¿s signature line. The 3month ISP Reviews will be monitored monthly by the Program Specialists at the sites. [Individual #1 signed and dated ISP review, 11/18/15 to 2/17/16 on 2/17/16. Program Specialist will complete ISP reviews for all individuals as required and ensure individuals sign and date the ISP reviews upon review. At least quarterly, the CEO will review a 25% sample of ISP reviews to ensure timeliness and required signatures and dates. Documentation of reviews shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |
6400.186(b) | Individual #1 did not date the ISP review signature sheet upon review of the ISP reviews ending 2/17/15, 5/17/15, 8/17/15 and 11/17/15. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | A date line has been added to MYCS 3 month ISP Review after the individual¿s signature line. The 3month ISP Reviews will be monitored monthly by the Program Specialists at the sites.[Individual #1 signed and dated ISP review, 11/18/15 to 2/17/16 on 2/17/16. Program Specialist will complete ISP reviews for all individuals as required and ensure individuals sign and date the ISP reviews upon review. At least quarterly, the CEO will review a 25% sample of ISP reviews to ensure timeliness and required signatures and dates. Documentation of reviews shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |
6400.213(13) | Individual #1's record did not include a copy of the psychological evaluation completed 4/23/1996. | Each individual's record must include the following information: Copies of psychological evaluations, if applicable. | Psychologicals will be collected and filed for all new residents prior to admission. This is a requirement on our Pre-Admission packet and will be monitored by the Program Specialist and Lead DSP> [Immediately, the program specialists will review all individual's record to ensure a copy of the psychological evaluation is present as required. At least quarterly reviews of individual records shall be completed by the program specialists or designated staff to ensure all individual records include the required documents including copies of psychological evaluations, if applicable. Documentation of record reviews shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |