| 6400.181(a) | The assessmen for Individual #2 was completed on 7/16/2014 and not again until 8/14/2015. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Provider¿s Residential Case managers were instructed to initiate reviews of all Residential Records to identify any additional compliance issues related to the completion of the Annual Assessment by 3/31/16. Case Managers will begin tracking skill assessment dates for all individuals as part of their ISP- Quarterly Tracking Log effective 5/1/16. Annual individual assessments identified as out of compliance will be revised immediately by the assigned Case Manager. Training Materials have been revised to include language reflecting the initial and annual requirements of the Skill Assessment. The Director of Case Management Services will complete random file audits quarterly throughout the year to ensure compliance with this regulation.
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04/15/2016
| Implemented |
| 6400.195(e)(3) | Individual #2's restrictive procedure plan dated 1/8/2016 restricts individual #2's access to the kitchen because she ¿has an obsession and compulsion to measure, pick items from the floor and place them in her mouth or check/pick at objects that she is preoccupied with." The target behavior continues by stating that she "may inappropriately touch staff and others when she is attempting to measure. For example, she may attempt to put her hands down your shirt, and she may attempt to measure herself which at times may lead to self-abusive behaviors." According to agency records, the behavior that is being monitored, recorded, and measured is how often individual #2 bangs on the locked kitchen door. There are no methods to modify or eliminate the targe behaviors of measuring, picking item off the floor, or picking at objects. | The restrictive procedure plan shall include: Methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior.
| The interdisciplinary team met to revise the SEEP and Restrictive Procedure Plan to clarify specific behaviors that present a significant safety risk when accessing the kitchen. Staff will be trained on the revised document by 5-3-16. |
05/03/2016
| Implemented |