| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(c) | The 11/5/17 incident for Individual #5 stated made up a lie to staff about staff slamming door in her face. The incident was never reported or investigated. | The home shall orally notify the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| 1. The Program Director/CEO completed education with the Program Manager specific to 6400.18 (c) on 5/09/18. Included: Orally notifying the IDD program of the county and the appropriate regional office of IDD with 24 hours after the suspected abuse of an individual. If appropriate report allegation to the licensed facility where the alleged abuse/unusual incident occurred. Follow-up with the county office of Regional Office to be certain the alleged abuse/unusual incident was received and properly investigated.
The Program Director/CEO and The Program Manager reviewed the Incident Management Policy/ Procedure training 5/10/18. This training Included: Purpose-the Policy-Reporting requirements such as: (abuse, suspected abuse, Injury, Trauma, Illness requiring inpatient hospitalization, suicide attempt, a violation or alleged violation of an individual¿s rights, an individual who is missing for more than 24 hours or who could be in jeopardy if missing at all, misuse or alleged misuse of an individual¿s funds or property, an outbreak of a serious communicable disease, an incident requiring the services of a fire department or law enforcement agency, any condition that results in closure of the facility for more than 1 scheduled day of operation. And/or the death of an individual) and procedure. The Program Director/CEO, Program Manager and the staff will do annual trainings on reporting and investigating Incident Management and annual reviews on the Policy and Procedures of IM reporting, so in the future no reportable incident will be over-looked.
The Program manager has put in place an in-service sign-in sheet for all staff to sign when reviewing the IM Policy and Procedures., this became effective immediately.
The Program Manager has put in place a reporting structure plan for staff to use as an assistance for reporting incidents. Program Manager put in place an incident report sheet for all staff to use when reporting an incident. After the staff has written the report on the designated incident report sheets, staff will need to verbally report the incident-they may report the incident to the Bleiler Caring Cottage Program Manager, Program Director/CEO and/or The Adult Daily Living Center Program Manager- whom will then report it to the Masonic Villages Executor Director and the Bleiler caring Cottage IM reporter so that she may file a report into EIM/HCSIS system and assign a certified investigator if needed. The new report structure plan and reporting sheets are located in the Incident management report binder.
On May 14, 2018 Program Manager reported into HCSIS/EIM a report in regards to an incident that occurred on 11/5/2017 with individual #5. At this time a certified investigator was assigned so that the incident may be investigated.
Copy attached. Attachments #18 and #19 |
05/14/2018
| Implemented |
| 6400.22(d)(1) | Individual #2 DOA was 1/5/18 and the home does not have a personal property record for him. The home has a policy in place that states the home isn't going to keep a record of personal possessions. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 1. Program Manager created a Personal Property record log and a financial record log.
2. Program Manager created a new ¿day of admissions¿ check list-for new individuals entering the program-including a personal property record log and financial record log (if applicable).
3. This list has been added to the Bleiler Caring Cottage admission packet and will be gone over with the individual on the day of admission, implemented on 5/17/2018.
4. Program Manager updated the Funds and Property policy in the policy and procedure manual which included:
Under Financial records-The Tracking sheets include the following: Name of Individual-Date-Balance-cash Received-cash withdrawal- cash returned- balance- If purchase was over $15 receipt attached and staff initials, at the bottom of each sheet is documentation of each staff full names followed by their initials.
Under personal Property: The Tracking Sheets include the following: Name of Individual-Date- Category for Furniture-name of item and how many- Category for electronic-name of item and how many, Category for Misc. including Clothing-personals-collectibles- name of items and how many. On the bottom the tracking sheet the resident will sign, the staff whom assistant the individual and the date.
5. This policy and procedure was implemented it on 5/18/2018.
6. Staff were trained by Program Specialist on 5/18/18 on the protection and adequate accounting of Individuals funds and property policy. Staff was issued copies of the policy and procedure and copies of our new personal property logging sheets. All staff signed stating they received copies.
Copies Attached. Attachment #4-#5-#6-#7-#15 |
05/18/2018
| Implemented |
| 6400.31(b) | Individual #2 DOA was 1/5/18 and he wasn't informed of his rights until 1/6/18. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | 1. The Program Director/CEO completed education with the Program Manager specific to 6400.31 (b) on 5/17/18.
2. Program Manager created a new ¿day of admissions¿ check list-for new individuals entering the program-including the resident rights- civil rights and grievance procedures.
3. This list has been added to the Bleiler Caring Cottage admission packet and will be gone over with the individual by the Program Manager on the day of admission.
4. On the Day of admissions The Program Director/CEO will review the ¿day of Admissions¿ Check list and all other forms to be sure that the Program manager did not miss going over any pertinent information with our new admission and to also ensure that our new admission has signed and has been given copies of their resident rights.
4. Program Manager has Implemented the new check-list and added new procedures on 5/17/2018
Copy Attached. Attachment #5 |
05/17/2018
| Implemented |
| 6400.43(b)(1) | The CEO didn't ensure the incident management policy was followed. IM policy states if employees have reasonable cause to suspect that a recipient is a victim of abuse or observes suspected abuse has occurred then will complete oral report and report to program director within 48 hours of oral report and then a written report will be completed. Suspected abuse should be investigated by a certified investigator. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | 1. The Program Director/CEO completed education with the Program Manager specific to 6400.18 (c) on 5/09/18. Included: Orally notifying the IDD program of the county and the appropriate regional office of IDD with 24 hours after the suspected abuse of an individual. If appropriate report allegation to the licensed facility where the alleged abuse/unusual incident occurred. Follow-up with the county office of Regional Office to be certain the alleged abuse/unusual incident was received and properly investigated.
The Program Director/CEO and The Program Manager reviewed the Incident Management Policy/ Procedure training 5/10/18. This training Included: Purpose-the Policy-Reporting requirements such as: (abuse, suspected abuse, Injury, Trauma, Illness requiring inpatient hospitalization, suicide attempt, a violation or alleged violation of an individual¿s rights, an individual who is missing for more than 24 hours or who could be in jeopardy if missing at all, misuse or alleged misuse of an individual¿s funds or property, an outbreak of a serious communicable disease, an incident requiring the services of a fire department or law enforcement agency, any condition that results in closure of the facility for more than 1 scheduled day of operation. And/or the death of an individual) and procedure. The Program Director/CEO, Program Manager and the staff will do annual trainings on reporting and investigating Incident Management and annual reviews on the Policy and Procedures of IM reporting, so in the future no reportable incident will be over-looked. The Program manager has put in place an in-service sign-in sheet for all staff to sign when reviewing the IM Policy and Procedures., this became effective immediately.
Copy attached. Attachments #18 |
05/10/2018
| Implemented |
| 6400.44(b)(10) | Staff #3 didn't complete, review, sign and date individual #2's January 2018 monthly documentation. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes. | DHS Inspectors educated Program Specialist on how to correctly prepare accurate monthly documentation and reviewing with the Program Specialist that monthly review must be done on every individual even in the month of admission.
Program Director/CEO completed education and reviewed the state regulation manual under 6400.44(b)(10) with the Program Specialist on 5/17/18.
Program Specialist made a monthly reviews- quarterly reviews- annual assessments-and annual ISP documentation schedule for each individual stating the month and date in which they are due by. This is to ensure that all documentation is being completed in the month it¿s due and in the future no Individual¿s is overlooked.
Program Director/CEO will review one individual¿s documentation sheets quarterly to ensure the Program Specialist is updating-signing and dating the monthly-quarterly-annual reviews. This is effective immediately.
Copies attached. Attachment #20 and #21 |
05/17/2018
| Implemented |
| 6400.44(b)(18) | No staff were trained in any health and safety needs, ISP, and the assessments of the individuals. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | DHS Inspectors educated Program Specialist on using correct documentation and educating her on reviewing the health and safety needs of each individual with staff.
Program Director/CEO completed education and reviewed the state regulation manual under 6400.44(b)(18) with the Program Specialist on 5/17/18.
Program Specialist will review each individual¿s health and safety needs with staff the day of admission and quarterly thereafter. The program Specialist will also update the staff if there are any changes with any individual¿s health and safety needs on an as needed basis.
Program Specialist has implemented a monthly check sheet for all staff to sign that they have reviewed each individual¿s Monthly¿s-quarterly¿s-annual ISP¿s and annual assessments. Program Specialist will check quarterly to ensure that all staff are indeed reviewing this information monthly.
Program Director/CEO will review one individuals check sheet quarterly to ensure that the program Specialist and staff are reviewing the documents quarterly and as needed when there are changes in the individual.
These changes were implemented on 5/30/2018.
Copies attached. Attachment #22 |
05/30/2018
| Implemented |
| 6400.103 | The written evacuation plan did not include means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| 1. The Program Specialist reviewed the evacuation procedures and made the needed changes and added the means of transportation during an evacuation.
2. This is how our Evacuation plan reads with our changes:
a) In case of an emergency evacuation, all staff and individuals in the cottage is to leave out the nearest emergency exit as listed in the diagrams located at each end of the home.
b) Once safely evacuated, all staff and individuals should meet in the parking lot in front of the house at the top of the hill on the sidewalk.
c) The staff will account for all individuals at this time and then staff and individuals will walk to the Weller House (The Masonic Villages Children¿s Home) two doors down on the right; this is approximately 200 feet away from the Bleiler Caring Cottage. Once our individuals are accounted for a second time; The Bleiler Caring Cottage staff will be responsible for retrieving the Masonic Villages Bleiler Caring Cottage van to transport staff and individuals by van to their safety location at The Patton Campus.
d) (If not already done) Once all individuals and staff have been safely moved to their safety location: The Program Manager and Bleiler caring Cottage CEO are to be notified.
2. Program Specialist added a copy to the fire drill log as well as to the policy and procedure manual and implemented the change on 5/09/2018
3. Program Manager educated all staff and gave them copies of the amended Policy and Procedure of our Fire Evacuation on 5/18/18. All staff signed stating they received copies.
Copy Attached. Attachment #3-#16 |
05/18/2018
| Implemented |
| 6400.106 | The furnace cleaning was done on 2/21/17 and there was no documentation since. | 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.
| 1. Program Director/CEO completed education with the Program Manager specific to 6400.106 on 5/18/2018 related to annual and timely inspections and cleaning of the facility furnace.
2. Program Manager notified Worley @ Obetz on 5/7/2018 that the furnace required inspection and cleaning.
3. Program Manager scheduled the inspection and cleaning for 5/25/2018 and the cleaning was completed on 5/25/2018.
4. To be sure that the furnace is cleaned and inspected within 365 days the Program Manager has documented the date on her calendar in order to track it. Program Manager has a copy of the invoice and checklist stating that our furnace was cleaned and serviced on 5/25/2018. There is also a dated copy of the cleaning and service checklist located on a clip board on the wall by the furnace to ensure Program Manager does not miss any future cleanings.
5. Effective immediately.
Copy attached. Attachment #13 |
05/25/2018
| Implemented |
| 6400.111(a) | The basement fire extinguisher was not charged. It was not in the green zone. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | 1. Bleiler Caring Cottage Program Manager notified The Masonic Village Fire and Safety department on 5/9/2018.
2. Fire and Safety corrected the fire extinguisher on 5/9/2018
3. Masonic Villages Security department will do monthly checks on all fire extinguishers and document accordingly.
4. The Manager of the Masonic Villages security department will do quarterly checks, to ensure that all checks are being done effectively and that all fire extinguishers are charged and in the green zone. If at this time any Fire Extinguishers are identified outside the green zone, Masonic Villages security will notify Fire and Safety and have it charged or replaced immediately. |
05/09/2018
| Implemented |
| 6400.112(d) | The fire drill held on 4/30/17 took 2:35 to evacuate and no additional drills were held. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | 1. Program Manager created a plan of action if there should be an individual in the future that cannot evacuate the building in the allotted time frame of 2 ½ minutes or less.
The plan of correction includes:
* Staff will conduct an additional fire drill within the same month. If the individual still does not make it out in the allotted time frame staff are to notify the Program Manager.
*The Program Manager will notify the local fire department and have them come to the cottage and pull their own drill to see if the allotted amount of time needs to be extended.
*The Program Specialist will evaluate any changes that will need to be made to the individuals care plan- stating they may no longer be home independently.
*The Program Manager will educate all staff of any changes that are implemented regarding any changes to a resident¿s evacuation plan.
2. Program Manager educated all staff and gave them copies of the Policy and Procedure for if an individual does not make it out in the allotted time frame of 2 ½ minutes on 5/18/18. All staff signed stating they received copies.
3. A copy has been added to the fire drill log book so all staff are informed of the procedure.
4. Program Manager has added this to the policy and procedure book and implemented on 5/9/2018.
Copy Attached. Attachments #2-#14 |
05/18/2018
| Implemented |
| 6400.112(e) | The fire drill records do not indicate dates of sleep drills. | A fire drill shall be held during sleeping hours at least every 6 months. | 1.The program manager updated a new monthly fire drill report sheet, adding check-off boxes for day drill-evening drill and sleep drill; also adding check-off boxes for am. and pm.
2. Program Manager (the day of or the day after) will review and sign on the monthly fire drill sheet that she has reviewed all areas to ensure that staff have filled in accurate information and has filled in all required information which is listed on the monthly fire drill report sheets, including the newly added check-off boxes for am-pm-for the day drill-evening drill and sleep drill.
3. Program Manager has educated staff on the monthly fire drill sheets with the new added information. All staff has received copies of the amended monthly fire drill logs on 5/18/18. All staff signed stating they received copies.
4. This change was implemented on 5/9/2018
Copy attached. Attachment #1-#17 |
05/18/2018
| Implemented |
| 6400.141(c)(13) | Physical dated 11/29/17 does not include Individual # 1's allergies. 11/29/16 physical and lifetime medical history as well as ISP and assessments indicate Seasonal Allergies. | The physical examination shall include: Allergies or contraindicated medications. | Program Specialist Reviewed individual #1 11/29/17 and 11/29/16 annual physical, lifetime medical history, ISP and annual assessment. 11/29/2017 physical did not include individual #1 seasonal allergies. Program Specialist made the needed corrections on individual #1 physical and returned it to individual #1 PCP he reviewed and signed indicating that the added information was correct. In the future The Program Specialist will add on the additional information to the physical form to ensure the needed and correct information is already on the physical form the day of individual #1 scheduled physical. The day of the scheduled physical before leaving staff will review the physical form while still in the presence of the PCP to ensure that all information is filled in and is correct.
Program Director/CEO will review one individuals physical form quarterly to ensure that all pertinent and correct information is on the physical forms. This became effective on May 30, 2018.
Copy attached. Attachment #23 |
05/30/2018
| Implemented |
| 6400.141(c)(14) | Individual # 1 is diagnosed a form of cancer, Myelfibrosis and Cerebellar Angenesis. These diagnosis were not contained in the Medical information pertinent to diagnosis and treatment in case of an emergency on the 11/29/17 physical exam. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist Reviewed individual #1 11/29/2017 annual physical and made the needed changes and returned it to individual #1 PCP he reviewed and signed indicating that medical information pertinent to his diagnosis is filled in correctly and all information has been added. In the future The Program Specialist will add on the additional information to the physical form under the medical information pertinent to diagnosis and treatment section of the physical to ensure the needed and correct information is already on the physical form the day of individual #1 scheduled physical. The day of the scheduled physical before leaving staff will review the physical form while still in the presence of the PCP to ensure that all pertinent information is filled in and is accurate.
Program Manager will review all individuals records to ensure that all information is provided and accurate.
Program Director/CEO will review one individuals physical form quarterly to ensure that all pertinent and accurate information is on the physical forms and that all pertinent areas are filled in.
This became effective on May 30, 2018.
Copy attached. Attachment #23 |
05/30/2018
| Implemented |
| 6400.141(c)(15) | Individual #2's physical dated 12/7/17 did not include their diet. | The physical examination shall include Special instructions for the individual's diet. | Program Manager reviewed Individual #2 12/7/2017 physical. Since this physical was done before individual #2 entered our program, the Program manager contacted individual #2 family to retrieve individual #2 PCP information to make contact with him.
Program Specialist updated the physical and reworded the diet area of the physical form to ensure that the PCP understands what is being asked and that is filled in- in the future. The day of the individuals scheduled physical before leaving the medical facility staff will review the physical form while still in the presence of the PCP to ensure that all pertinent information is filled in and is accurate including their diet portion of the form. The Program Manager will review all individuals physicals annually to ensure that the all information is updated and accurate. Effective immediately 5/31/18
Copy attached. Attachment #26 |
05/31/2018
| Implemented |
| 6400.142(f) | Individual #2's dental hygiene plan indicated he was independent. According to staff #3 he needs verbal reminders to complete all hygiene tasks. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Program Specialist reviewed individual #1¿s dental hygiene plan. After reviewing the plan the Program Specialist made the needed changes. The program Specialist made and put in place a Dental Hygiene reminder check-off form for the individual and for all staff to document when reminders are needed. Program Specialist also updated the individual¿s dental hygiene plan to reflect the changes. The program Specialist will review the dental hygiene plan and check off forms on a quarterly basis to ensure that his needs are being met appropriately.
The program Manager/CEO will review one individual¿s dental hygiene plan quarterly to be sure that all pertinent information is his dental Hygiene Plan.
Effective immediately 5/31/2018
Copies attached. Attachment #27-#28 |
05/31/2018
| Implemented |
| 6400.181(e)(3)(i) | Individual #2's assessment dated 2/9/18 did not include current level of performance and progress in acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | 1. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
2. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are met.
3. Program Director/CEO will review at least one individual¿s annual assessment on a quarterly basis to be sure that all categories are met.
4. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment. The check list will include the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )-(181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)-(181)(e)(4)-(181)(e)(5) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-)-(181)(e)(10)-(181)(e)(11)-(181)(e)(12)-(181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix)-(181)(e)(14)-(181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. The program specialist will use this check list with each individual assessment when reviewing and updating annual assessments.
6. Changes were implemented on 5/21/18
Copy is attached. Attachment #8-attachment #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(3)(ii) | Individual #2's assessment dated 2/9/18 did not include current level of performance and progress in communication. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | 1. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
2. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
3. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and she will use this check list with each individual assessment when reviewing and updating annual assessments to ensure that all assessments include the required DHS regulation categories.
4. Program Director/CEO will review at least one individual¿s annual assessment on a quarterly basis to be sure each individual¿s assessment are meeting the DHS required categories.
5. Changes were implemented on 5/21/18
Copy is attached. Attachment #8-attachment #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(3)(iii) | Individual #2's assessment dated 2/9/18 did not include current level of performance and progress in personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | 1. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
3. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and she will use this check list with each individual assessment when reviewing and updating annual assessments to ensure that all assessments include the required DHS regulation categories.
4. Program Director/CEO will review at least one individual¿s annual assessment on a quarterly basis to be sure each individual¿s assessment are meeting the DHS required categories
5. Changes were implemented on 5/21/18
Copy is attached. Attachment #8-attachment #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(3)(iv) | Individual #2's assessment dated 2/9/18 did not include current level of performance and progress in personal needs with or without assistance from others. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | 1. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
3. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and she will use this check list with each individual assessment when reviewing and updating annual assessments to ensure that all assessments include the required DHS regulation categories.
4. Program Director/CEO will review at least one individual¿s annual assessment on a quarterly basis to be sure each individual¿s assessment are meeting the DHS required categories.
5. Changes were implemented on 5/21/18
Copies are attached. Attachment #8-attachment #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(4) | Individual #2's assessment dated 2/9/18 did not include the supervision needs. The assessment indicated he would have an indefinite amount of time at home another part stated he could have up to 8 hours if needed in the home and community. | The assessment must include the following information: The individual's need for supervision.
| 1. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
3. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and she will use this check list with each individual assessment when reviewing and updating annual assessments to ensure that all assessments include the required DHS regulation categories.
4. Program Director/CEO will review at least one individual¿s annual assessment on a quarterly basis to be sure each individual¿s assessment are meeting the DHS required categories. While reviewing each Assessment category the Program Director/CEO will be checking to ensure that supervisory needs are included and that all information is accurate.
The Program Specialist will review all individual¿s ISP¿s-Assessments-Monthly¿s and quarterly-s to ensure that all supervisory needs are accurate and identical in all the individuals paperwork.
5. Changes were implemented on 5/21/18
Copies are attached. Attachment #8-attachment #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(9) | Individual #2's assessment dated 2/9/18 did not include documentation of his hypertriglyceridemia diagnosis that was included on the 12/7/17 physical form. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Program Specialist reviewed individuals #2 2/9/2018 assessment and 12/7/2017 physical. Program Specialist reached out to his family on May 23, 2018 for information in regards to his hypertriglyceridemia diagnosis, the family said they would reach out to his doctor, Program Specialist reached out to the family again on May 31, 2018 and requested contact information in regards to his past physician. Program Specialist contacted the physician and the physician¿s office faxed the information in regards to individual #2 hypertriglyceridemia diagnosis. Program Specialist attached a copy to individual #2¿s physical and added the diagnosis information to individual #2¿s assessment.
In the future when our program admits a new individual The Program Manager will review all incoming individuals physical for any information that needs to be followed up on-if there is needed information that needs clarification, the Program Manager will contact the individuals former doctor and/or family for the required information. Program Manager will review all individuals records to ensure that all information is provided and accurate.
Changes were implemented on May 31, 2018. |
05/31/2018
| Implemented |
| 6400.181(e)(12) | Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim in the area of recommendations for specific areas of training programming and services. Individual #2's assessment dated 2/9/18 did not include recommendations for training, services and programming. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist reviewed Individual #1¿s assessment 6400.181(12) and made the needed changes.
4. Moving forward when the Program Specialist updates the individual¿s annual assessment she will carefully review each category to make sure they are not verbatim from the previous year¿s assessment.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. The Program Director/CEO will review atleast one individual¿s current annual assessment and the prior year annual assessment on a quarterly basis to ensure that the Program Specialist is reviewing the annual assessments properly and there are no categories written verbatim from the previous year.
Changes were implemented on 5/23/2018.
Copy attached. Attachment #10 and #11 |
05/23/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #2's assessment did not include the current level in health. It was copy and pasted from another individual's assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating assessments.
2. Program Director completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Manager will review and compare at least two individual¿s annual assessments on a quarterly basis to ensure that each individual has information pertaining to themselves and is not copy and pasted from another individual¿s assessment.
4. Program specialist reviewed both Individual #1 and individual #2 and made the changes indicating each as their own individual.
5. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
6. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment.
7. The program specialist will use this check list with each individual assessment when reviewing and updating annual assessment.
8. Changes were implemented on 5/21/18
Copies are attached. Attachment #8 and #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(13)(ii) | Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim in the area of Motor and Communication skills. Individual #2's assessment dated 2/9/18 did not have current level for motor and 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. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist reviewed Individual #1¿s assessment 6400.181(13)(ii) and made the needed changes.
4. Moving forward when the Program Specialist updates the individual¿s annual assessment she will carefully review each category to make sure they are not verbatim from the previous year¿s assessment.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. The Program Director/CEO will review atleast one individual¿s current annual assessment and the prior year annual assessment on a quarterly basis to ensure that the Program Specialist is reviewing the annual assessments properly and there are no categories written verbatim from the previous year.
Changes were implemented on 5/23/2018.
Copy attached. Attachment #10 and #11 |
05/23/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim in the area of Residential Living Activities. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist reviewed Individual #1¿s assessment 6400.181(13)(iii) and made the needed changes.
4. Moving forward when the Program Specialist updates the individual¿s annual assessment she will carefully review each category to make sure they are not verbatim from the previous year¿s assessment.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. The Program Director/CEO will review atleast one individual¿s current annual assessment and the prior year annual assessment on a quarterly basis to ensure that the Program Specialist is reviewing the annual assessments properly and there are no categories written verbatim from the previous year.
Changes were implemented on 5/23/2018.
Copy attached. Attachment #10 and #11 |
05/23/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual #2's assessment did not include the current level in activities of residential living. It was copy and pasted from another individual's assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program specialist reviewed both Individual #1 and individual #2 annual assessments and made the changes indicating each as their own individual.
4. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individual¿s assessment is not being used as a template for others.
6. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment- the Program Specialist will use this check list with each individual assessment when reviewing and updating annual assessments.
Changes were implemented on 5/21/18
Copies are attached. Attachment #8 and #9and attachment #12 |
05/23/2018
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2's assessment did not include the current level in personal adjustment. It was copy and pasted from another individual's assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program specialist reviewed both Individual #1 and individual #2 annual assessments and made the changes indicating each as their own individual.
4. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individual¿s assessment is not being used as a template for others.
6. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment she will use this check list with each individual assessment when reviewing and updating annual assessments.
8. Changes were implemented on 5/21/18
Copy attached. Attachment #8 and #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(13)(v) | Individual #2's assessment did not include the current level in socialization. It was copy and pasted from another individual's assessment. Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim in the area of Socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program Specialist reviewed Individual #1¿s assessment 6400.181(13)(v) and made the needed changes.
4. Moving forward when the Program Specialist updates the individual¿s annual assessment she will carefully review each category to make sure they are not verbatim from the previous year¿s assessment.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. The Program Director/CEO will review atleast one individual¿s current annual assessment and the prior year annual assessment on a quarterly basis to ensure that the Program Specialist is reviewing the annual assessments properly and there are no categories written verbatim from the previous year.
6. Changes were implemented on 5/23/2018.
Copy attached. Attachment #10 and #11 |
05/23/2018
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2's assessment did not include the current level in recreation. It was copy and pasted from another individual's assessment. Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim 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. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program specialist reviewed both Individual #1 and individual #2 annual assessments and made the changes indicating each as their own individual.
3. Program Director/CEO reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
4. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
5. Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individuals assessment is not being used as a template for others.
6. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment- She will use this check list with each individual assessment when reviewing and updating annual assessments.
Changes were implemented on 5/21/18
Copy attached. Attachment #8 and #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's assessment did not include the current level in financial indpendence. It was copy and pasted from another individual's assessment. Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim 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.
| 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating assessments.
2. Program specialist reviewed both Individual #1 and individual #2 and made the changes indicating each as their own individual.
3. Program Specialist reviewed the state regulation manual from 6400.181(e) through 6400.181(f).
4. Program Manager created a Personal Property record log and a financial record log.
5. Financial and Personal property logs will be presented to the individual and their families at the day of admission.
6. (If applicable) Staff in the view of family and the individual will document on the financial log the balance that was handed to staff on the day of admission
Under Financial records-The Tracking sheets include the following: Name of Individual-Date-Balance-cash Received-cash withdrawal- cash returned- balance- If purchase was over $15 receipt attached and staff initials, at the bottom of each sheet is documentation of each staff full names followed by their initials.
Under personal Property: The Tracking Sheets include the following: Name of Individual-Date- Category for Furniture-name of item and how many- Category for electronics-name of item and how many, Category for Misc. including Clothing-personals-collectibles- name of items and how many. On the bottom the tracking sheet the resident will sign, the staff whom assistant the individual and the date.
7. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
8. Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individual¿s assessment is not being used as a template for others.
9. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and Program Specialist will use this check list with each individual assessment when reviewing and updating annual assessments.
10. Changes were implemented on 5/21/18
Copies attached. Attachments #6- #8-#9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(13)(viii) | Individual #2's assessment did not include the current level in managing personal property. It was copy and pasted from another individual's assessment. Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim 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. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating assessments.
2. Program specialist reviewed both Individual #1 and individual #2 and made the changes indicating each as their own individual.
3. Program Specialist reviewed the state regulation manual from 6400.181(e) through 6400.181(f).
4. Program Manager created a Personal Property record log and a financial record log.
5. Financial and Personal property logs will be presented to the individual and their families at the day of admission.
6. (If applicable) Staff in the view of family and the individual will document on the financial log the balance that was handed to staff on the day of admission
Under Financial records-The Tracking sheets include the following: Name of Individual-Date-Balance-cash Received-cash withdrawal- cash returned- balance- If purchase was over $15 receipt attached and staff initials, at the bottom of each sheet is documentation of each staff full names followed by their initials.
Under personal Property: The Tracking Sheets include the following: Name of Individual-Date- Category for Furniture-name of item and how many- Category for electronics-name of item and how many, Category for Misc. including Clothing-personals-collectibles- name of items and how many. On the bottom the tracking sheet the resident will sign, the staff whom assistant the individual and the date.
7. Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
8. Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individual¿s assessment is not being used as a template for others.
9. The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment and Program Specialist will use this check list with each individual assessment when reviewing and updating annual assessments.
10. Changes were implemented on 5/21/18
Copies attached. Attachments #6- #8-#9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(e)(13)(ix) | Individual #2's assessment did not include the current level in community integration. It was copy and pasted from another individual's assessment. Individual # 1's 11/11/16 assessment and 11/10/17 assessment were verbatim in the area of Community Integration. | 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. | 1. DHS Inspectors educated Program Specialist specific to 6400.181 and creating accurate assessments.
2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
3. Program specialist reviewed both Individual #1 and individual #2 and made the changes indicating each as their own individual.
4. Program Specialist reviewed the state regulation manual from 6400.181(e) through 6400.181(f).
Program Specialist made an assessment check list-listing all categories from the state regulation manual from 6400.181(e) through 6400.181(f) to insure that all categories are listed and met.
The check list includes the following categories from the 6400 DHS Regulations:
(181)(e)(1)-181)(e)(2 )- (181)(e)(3)(i)-(181)(e)(ii-)-(181)(e)(iii)-(181)(e)(3)(iv)- (181)(e)(4)- (181)(e)(5-) (181)(e)(6)- (181)(e)(7) (181)(e)(8-) (181)(e)(9-) (181)(e)(10)- (181)(e)(11)- (181)(e)(12)- (181)(e)(13)(i)-(181)(e)(13)(ii)-(181)(e)(13)(iii)-(181)(e)(13)(iv)-(181)(e)(13)(v)-(181)(e)(13)(vi)-(181)(e)(13)(vii)-(181)(e)(13)(viii)-(181)(e)(13)(ix) -(181)(e)(14)- (181)(f)-Documentation with the date it was reviewed with the individual and that each team member including the Individual were given/sent copies.
The program specialist will make sure there is a copy of the check list with each individual¿s annual assessment. Program Specialist will use this check list with each individual assessment when reviewing and updating annual assessments.
5.Program Director/CEO will review at least two individuals¿ annual assessment on a quarterly basis to be sure that The Program Specialist is making sure that both individuals information is directed to the individual and that another individual¿s assessment is not being used as a template for others.
Changes were implemented on 5/21/18
Copy Attached. Attachment #8 and #9 and attachment #12 |
05/21/2018
| Implemented |
| 6400.181(f) | Individual #2's assessment sent to his brother on 2/9/18. This was the day of his ISP meeting. Individual #2 was not given a copy of the assessment.
Individual # 1's assessment dated 11/10/17. ISP meeting was held same date 11/10/17. Assessment not provided to plan team members 30 days before ISP meeting. | (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).
| 1. DHS Inspectors educated Program Specialist specific to 6400.181(f) on notifying/informing team members of the results of the individual¿s assessment at least 30 days prior to the meeting. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.181(e) through 6400.181(f) with the Program Specialist on 5/17/18.
Program Specialist reviewed individual #1¿s and individuals #2 annual assessment-in the future Program Specialist will be sure to follow the mandated regulation stating that all plan team members were informed of the results of the assessment at least 30 calendar days prior to the ISP. The program Specialist will be sure that all individuals receive a copy of their assessments the day they are reviewed with them. The program specialist created a Monthly-Quarterly ISP-Annual ISP and Annual assessment chart for all individuals with the dates for their monthly-quarterly reviews and for their annual ISP and annual Assessments, dating the assessments due date as 30 days before the annual ISP is due. Program Specialist will review all individual¿s records to ensure all individuals annual Assessments will be sent to the plan team 30 days before the individual¿s annual ISP meeting and that the individual receives a copy. The Program Director/CEO will review atleast one individual¿s current annual assessment annually to ensure that the Program Specialist has documentation that the annual assessment was sent 30 prior to the individual¿s annual ISP and that there is documentation that the individual received a copy of his/her annual assessment. Effective immediately.
Copy attached. Attachment #20. |
05/17/2018
| Implemented |
| 6400.183(3) | Individual #2's ISP did not include the method of evaluation for the socialization outcome. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | 1. DHS Inspectors educated Program Specialist specific to 6400.183(3) on how to evaluate individual #2¿s socialization outcome. Program Specialist reviewed individuals #2 socialization outcome and added the required information. Program Specialist has put into place steps to ensure that individual #2 meets his socialization outcome. Step 1- Program Specialist met individual #2¿s to inquire about his interests and what jobs-activities he has done in the past and what he may be interested in pursuing in the future. Step 2- The Program Specialist and staff have researched volunteering/job opportunities and activities that meet individual #2¿s interest. Step 3- The Program Specialist has made arrangements for individual #2 to volunteer at local establishments and participate in local activities. Such as: one of individual #2 interests was hanging out at the local fire hall. Step 4-The program specialist will implement a goal plan on tracking individual #2¿s socialization outcome goal. Step 5- Program Specialist educated the direct Care staff on how to evaluate and document in the goal tracking log. The staff will log daily in Individual #2¿s goal plan. The Program Director/CEO will review one individuals goal plan tracking log quarterly to ensure that staff are following through with their documentation. Program Specialist will review all individual¿s ISP¿s goals and records to ensure all individuals outcomes are being tracked and logged. Effective Immediately
Copy attached. Attachment #28 |
05/28/2018
| Implemented |
| 6400.183(4) | Individual #2's ISP stated he could be unsupervised at home and community for 12 hours or more if needed. The ISP did not specify a time and did not address his level of need. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | DHS Inspectors educated Program Specialist specific to 6400.183(4) on how to evaluate individual #2¿s unsupervised time. The Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. It was shared with Individual #2 team that Individual #2 may be left unsupervised in the community and in the home for 12 hours or more if needed, when residing with his father, he would get up get ready for the day and take a walk into town and he could come and go at his choosing. There is a sign in/out log that Individual #2 signs so that staff are aware of his ware abouts at all times. He will be evaluated on his monthly-quarterly-and annual reviews in case there would be any changes in his needs. Program Specialist will review all individuals records to make sure that all information is accurate and matching. Program Director/CEO will review at least one individuals¿ annual ISP quarterly to be sure that The Program Specialist is documenting accurately. Effective immediately. |
06/04/2018
| Implemented |
| 6400.183(7)(i) | Individual #2's ISP did not include the potential to advance in residential independence. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Residential independence. | 1. DHS Inspectors educated Program Specialist specific to 6400.183(7)(i) on how to evaluate individual #2¿s residential Independence. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18.
Program Specialist reviewed individuals #2 ISP plan and provided the needed changes in advance in residential independence. Individual #2 is new to our program as of January. He is becoming more familiar with our program. Individual #2 is independent in most areas of the cottage- he does need staff supervisor when cooking on the stove, he does show interest in wanting to be independent with the stove, staff will work with him on becoming better familiar with using the stove. Individual #2 recently started riding his bike around campus-starting just by riding up the road-each week he takes himself a little further as he becomes more familiar with our campus. Individual #2 walks himself to his volunteer job on campus every Monday and to the Wellness Center almost daily. Program specialist will document individual #2 progress through quarterly ISP¿s and annual ISP¿s and annual assessments. Program Specialist will review all individuals records to ensure that all individuals are being documented under 6400.183(7)(i) the potential to advance in residential independence. Program Specialist Has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that all individuals advance in residential independence section is updated. Program Director/CEO will review one individuals records quarterly to ensure that all required information under regulations 6400.183 through 6400.190(c) has been added and updated in all individual¿s record. Effective 6/4/2018.
Copy attached. Attachment #30 |
06/04/2018
| Implemented |
| 6400.183(7)(ii) | Individual #2's ISP did not include the potential to advance in community involvement. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Community involvement. | 1. DHS Inspectors educated Program Specialist specific to 6400.183(7)(ii) on how to evaluate individual #2¿s community Involvement. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. Program Specialist reviewed individuals #2 ISP plan and provided the needed changes in advance in residential independence. Individual #2 is new to program and community. Staff have taken individual #2 around the MV campus and out in the local community. As individual becomes familiar with our campus and our community he will be given opportunities to ride his bike or walk into town, he is the process of joining the Elizabethtown fire company and as honorary member. Individual #2 volunteers one day a week at the local library; he hopes to be able to pick up an extra day or two once he becomes better familiar his tasks. Individual #2 volunteers one day a week at the Masonic Villages health care center- delivering and putting away residents clothing- he has asked his supervisor about picking up an extra day- she is looking into where else they may be able to use him. Program specialist will document individual #2 progress through quarterly ISP¿s and annual ISP¿s and annual assessments. Program Specialist will review all individuals records to ensure that all individuals are being documented under 6400.183(7)(ii) the potential to advance in community involvement. Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that all individuals advance in community involvement section is updated. Program Director/CEO will review one individuals records quarterly to ensure that all required information under regulations 6400.183 through 6400.190(c) has been added and updated in all individual¿s record. Effective 6/4/2018.
Copy attached. Attachment #30 |
06/04/2018
| Implemented |
| 6400.183(7)(iii) | Individual #2's ISP did not include the potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | 1. DHS Inspectors educated Program Specialist specific to 6400.183(7)(iii) on how to evaluate individual #2¿s potential to advance in vocational programming. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. Program Specialist reviewed individuals #2 ISP plan and provided the needed changes in advance in vocational programming. Individual is already volunteering (2) days a week. One day at the Public Library and one day the Masonic Villages Health Care Center he is currently attending The Adult Daily Living Program (2) days a week. Individual #2 has inquired at both volunteering jobs about picking up extra days. So there is potential for him to advance with more days. Individual #2 applied to be a volunteer honorary fire man at the Elizabethtown Fire Hall. He is just waiting to hear back.
Program specialist will document individual #2 progress through quarterly ISP¿s and annual ISP¿s and annual assessments. Program Specialist will review all individuals records to ensure that all individuals are being documented under 6400.183(7)(iii) the potential to advance in vocational programming. Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that all individuals advance in vocational programming section is updated. Program Director/CEO will review one individuals records quarterly to ensure that all required information under regulations 6400.183 through 6400.190(c) has been added and updated in all individual¿s record. Effective 6/4/2018.
Copy attached. Attachment #30 |
06/04/2018
| Implemented |
| 6400.183(7)(iv) | Individual #2's ISP did not include the potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| 1. DHS Inspectors educated Program Specialist specific to 6400.183(7)(iv) on how to evaluate individual #2¿s potential to advance in competitive integrated employment. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. Program Specialist reviewed individuals #2 ISP plan and provided the needed changes in advance in competitive integrated employment. Before arriving to our program individual #2 worked in janitorial for a school district for approximately 26 years, but took early retirement. He said at this point he just wants to familiarize himself with the community; and just work at his volunteer jobs; but maybe in the future he would consider apply for competitive employment.
Program specialist will document individual #2 progress through quarterly ISP¿s and annual ISP¿s and annual assessments. Program Specialist will review all individuals records to ensure that all individuals are being documented under 6400.183(7)(iv) the potential to advance in competitive integrated employment. Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that all individuals advance in competitive integrated employment section is reviewed and updated. Program Director/CEO will review one individuals records quarterly to ensure that all required information under regulations 6400.183 through 6400.190(c) has been added and updated in all individual¿s record. Effective 6/4/2018.
Copy attached. Attachment #30 |
06/04/2018
| Implemented |
| 6400.184(a)(1)(iii) | There was no direct service worker at the initial ISP meeting for individual #2 on 2/9/18. | A plan team must include as its members the following: A direct service worker who works with the individual from each provider delivering services to the individual. | DHS Inspectors educated Program Specialist specific to 6400.184(a)(1)(iii) on there needs to be a Direct Care Staff need to be present and each/all individual¿s Annual ISP meeting. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. The Program Specialist has been made is aware that she may not play dual roles at the individuals annual ISP meetings. In the future the Program Specialist will be sure there is a Direct Care Staff available and will attend every individual annual ISP meeting.
Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that 6400.184(a)(1)(iii) section is reviewed and completed accurately.
The Program Director/CEO will review atleast one individual¿s current annual ISP annually to ensure that the Program Specialist has invited a Direct Care Staff and that there is documentation that a Direct Care Staff has signed and attended each individual¿s Annual ISP meetings. Effective 6/4/2018.
Copy attached. Attachment #30 |
06/04/2018
| Implemented |
| 6400.185(b) | Individual #2's ISP did not indicate if they were able to handle financial independence. Staff #3 stated he receives cash from his brother and puts it in his wallet and is not able to get change. | The ISP shall be implemented as written. | DHS Inspectors educated Program Specialist specific to 6400.185(b). If the individual need assistance in handling his money then the program must have some type of financial record in place to assist the individual. The Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. The Program Manager created a financial record log. The Financial logs will be presented to the individual and their families at the day of admission. (If applicable) Staff in the view of family and the individual will document on the financial log the balance that was handed to staff on the day of admission. Under Financial records-The Tracking sheets include the following: Name of Individual-Date-Balance-cash Received-cash withdrawal- cash returned- balance- If purchase was over $15 receipt attached and staff initials, at the bottom of each sheet is documentation of each staff full names followed by their initials. Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that 6400.185(b) section is reviewed and completed accurately. Program Director/CEO will review at least one individuals¿ financial log records annually to be sure that The Program Specialist and the Direct Care Staff are documenting accurately. Effective immediately.
Copies attached. Attachment #6-#30 |
06/04/2018
| Implemented |
| 6400.186(a) | Individual #2's DOA was 1/5/18 and they haven't had an ISP review completed to date. | 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. | DHS Inspectors educated Program Specialist specific to 6400.186(a). Program Specialist is also the Support Coordinator for individual #2 since he is private pay. It was explained to the program Specialist that the ISP review must be done with-in 3 months of admission date. The Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. Program Specialist made a monthly reviews- quarterly reviews- annual assessments-and annual ISP documentation schedule for each individual stating the month and date in which they are due by. This is to ensure that all documentation is being completed in the month the quarterly ISP review is due (Which is within 3 months of admissions date of the ARUD(Annual review update date) and in the future no Individual¿s quarterly ISP review will be overlooked.
The Program Specialist will review all individuals records to ensure that all quarterly reviews are done in the allotted time frame.
Program Director/CEO will review one individual¿s quarterly ISP reviews documentation sheets quarterly to ensure the Program Specialist is writing and presenting the quarterly reviews in the allotted time. This is effective immediately.
Copies attached. Attachment #20 |
06/04/2018
| Implemented |
| 6400.186(c)(2) | Individual # 1's ISP reviews dated 05/04/18, 02/06/18, 11/06/17 and 08/04/17 do not provide updated of dental plan utilization. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | 1. DHS Inspectors educated Program Specialist specific to 6400.186(c)(2) on how to accurately provide individual #1¿s quarterly ISP¿s reviews with an updated dental plan. 2. Program Director/CEO completed education and reviewed the state regulation manual from 6400.183 through 6400.190(c) with the Program Specialist on 6/4/18. Program Specialist reviewed individuals #1¿s 5/4/18-2/6/18-11/6/17 and 8/417 quarterly ISP plans and provided the needed changes in updating individuals #1¿s dental plan. Program Specialist has put an ISP check list (taken directly from the annual ISP)-into place to ensure that in the future that 6400.186(c)(2) section is reviewed and completed accurately and that there are changes documented under individual #1¿s dental plan in each quarterly review. Program Specialist will review all individuals records to ensure that their dental plans are being documented and updated quarterly. Program Director/CEO will review at least one individuals¿ ISP quarterly review records quarterly to be sure that The Program Specialist is documenting accurately. Effective Immediately.
Copy attached. Attachment #30. |
06/04/2018
| Implemented |