Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2390.33(b)(1) | Staff #1 and Staff #2 did not receive training on program specialist responsibilities. | The program specialist shall be responsible for the following: Coordinating and completing assessments.
(2) Providing the assessment as required under § 2390.151(f) (relating to assessment).
(3) Participating in the development of the ISP, including annual updates and revisions of the ISP.
(4) Attending the ISP meetings.
(5) Fulfilling the role of plan lead, as applicable, under § § 2390.152 and 2390.156(f) and (g) (relating to development, annual update and revision to the ISP; and ISP review and revision).
(6) Reviewing the ISP, annual updates and revisions for content accuracy.
(7) Reporting content discrepancy to the SC or plan lead, as applicable, and plan team members.
(8) Implementing the ISP as written.
(9) Supervising, monitoring and evaluating services provided to the client.
(10) Reviewing, signing and dating the monthly documentation of a client¿s participation and progress toward outcomes.
(11) Reporting a change related to the client¿s needs to the SC or plan lead, as applicable, and plan team members.
(12) Reviewing the ISP with the client as required under § 2390.156.
(13) Documenting the review of the ISP as required under § 2390.156.
(14) Providing documentation of the ISP review to the SC or plan lead, as applicable, and plan team members as required under § 2390.156(d).
(15) Informing plan team members of the option to decline the ISP review documentation as required under § 2390.156(e).
(16) Recommending a revision to a service or outcome in the ISP as provided under § 2390.156(c)(4).
(17) Coordinating the services provided to a client.
(18) Coordinating the training of direct service workers in the content of health and safety needs relevant to each client.
(19) Developing and implementing provider services as required under § 2390.158 (relating to | Checklist of regulation 2390.33 Program Specialist responsibilities reviewed and signed by Program Specialist and Program Specialist Manager. |
10/21/2016
| Implemented |
2390.67 | Purell hand sanitizer and Spray Nine bottles were unlocked in the main program area. Flammable Liquid was unlocked in the basement work area, Sani-cloth disinfectant wipes were unlocked in the program area, and disinfectant was unlocked in the men's bathroom. | Safe and sanitary conditions shall be provided while handling supplies, packaging products and carrying out work functions. | The Purell hand sanitizer has been removed from the program area. The Spray Nine bottles are kept in a locked container when not in use. When in use, the use of the bottles is supervised directly by staff. The Flammable Liquids cabinet has been locked, and will remain locked with access by staff only. Sani-cloth disinfectant wipes have been placed in a locked cabinet, which will only by accessed by staff as well. The disinfectant in the men's bathroom has been removed and disposed of. |
10/21/2016
| Implemented |
2390.124(10) | Individual #1's record did not contain a current copy of the Individual Support Plan. | Each client's record must include the following information: A copy of the current ISP. | Quarterly Checklist: Copy of current ISP
See questions and attachment #13 |
10/21/2016
| Implemented |
2390.124(12) | Individual #4's 4/22/16 assessment indicated he/she was safe and was not safe with poisonous materials. Indvidual #4's Individual Support Plan indicated he/she was safe with poisons. Individual #2's social, emotional, environmental needs plan indicated a behavior support plan was in place. Individual #2's Individual Support Plan (ISP) indicated there was not a behavior support plan in place. Individual #3's ISP indicated Clonazepam and Buproprion were treating depression. The social, emotional, environmental needs plan indicated medications were treating mood disorder, major depressive disorder, and rec nos. | Each client's record must include the following information: Content discrepancy in the ISP, the annual update or revision under § 2390.156. | Clarification of discrepancies will be discussed with team members at ISP meeting.
Discrepancies will be corrected in so mentioned files |
06/30/2017
| Implemented |
2390.151(c) | Individual #5's 1/5/16 assessment did not include the basis of the assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Assessment Checklist: Checklist to include assessment based on assessment instruments, interviews, progress notes and observations. Checklist reviewed by staff other than clients Program Specialist.
See questions and attachment #4 |
10/21/2016
| Implemented |
2390.151(e)(6) | Individual #6's 2/1/16 assessment and Individual #7's 4/19/16 assessment did not include knowledge of safety around poisons. | The assessment must include the following information: The client's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Assessment Checklist: Checklist to include knowledge of safety around poisonous materials. Checklist reviewed by staff other than clients Program Specialist.
See questions and attachment #5 |
10/21/2016
| Implemented |
2390.151(e)(9) | Individual #8's 3/12/16 assessment did not include information regarding his/her vegal nerve stimulator, seizures, or his/her inability to ambulate stairs. Individual #11's 8/16/16 assessment and Individual #5's 1/5/16 assessment did not include functional and medical limitations. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | Assessment Checklist: Checklist to include functional and medical limitations . Checklist reviewed by staff other than clients Program Specialist.
See Questions and attachment #6 |
10/21/2016
| Implemented |
2390.151(e)(10) | Individual #10's 11/9/15 assessment and Individual #8's 3/24/16 assessment did not include an updated medical history. Individual #3's 4/29/16 assessment, Individual #6's 2/1/16 assessment, Individual #11's 8/16/16 assessment, Individual #7's 4/19/16 assessment, and Individual #5's 1/5/16 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Assessment Checklist: Checklist to include lifetime medical history (Attached) Assessment checklist to be reviewed by staff other than client's Program Specialist.
Annual Checklist: Checklist to include Lifetime medical updated. Annual checklist will be reviewed by Rehab Manager |
10/21/2016
| Implemented |
2390.151(e)(13)(i) | Individual #8's 3/24/16 assessment, Individual #7's 4/19/16 assessment, and Individual #6's 2/1/16 assessment did not include progress over the past year in health. | 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. | Assessment Checklist: Checklist to include progress over the past year in health. Checklist to be reviewed by staff other then the clients Program Specialist.
See questions and attachment #7 |
10/21/2016
| Implemented |
2390.151(e)(13(ii) | Individual #2's 5/20/16 assessment, Individual #6's 2/1/16 assessment, Individual #7's 4/19/16 assessment, and Individual #11's 8/16/16 assessment did not include progress over the past year in motor and communicaiton skills. | 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. | Assessment Checklist: Checklist to include progress over the past year in motor and communication skills. Checklist to be reviewed by staff other then the clients Program Specialist.
See questions and attachment #8 |
10/21/2016
| Implemented |
2390.151(e)(13)(iii) | Individual #6's 2/1/16 assessment and and Individual #11's 8/16/16 assessment did not include progress over the past year in personal adjustment. | 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. | Assessment Checklist to include progress over the past year in personal adjustment. Checklist reviewed by staff other than clients Program Specialist.
See questions and attachment #9 |
10/21/2016
| Implemented |
2390.151(e)(13(iv) | Individual #9's 5/20/16 assessment and Individual #11's 8/16/16 assessment did not include progress over the past year in 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. | Assessment Checklist to include progress over the past year in socialization. Checklist reviewed by staff other than clients Program Specialist.
See questions and attachment #10 |
10/21/2016
| Implemented |
2390.151(e)(13)(v) | Individual #6's 2/1/16 assessment and Individual #8's 3/24/16 assessment did not include progerss over the past year in vocational skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Vocational skills. | Assessment Checklist: Checklist to include progress over the past year in vocational skills. Checklist to be reviewed by staff other then the clients Program Specialist.
See questions and attachment #11 |
10/21/2016
| Implemented |
2390.151(f) | There was no documentation to show Individual #3¿s 4/29/16 assessment and Individual #6's 2/1/16 assessment was sent to plan team members. Individual #5's 1/5/16 assessment was sent on 1/5/16 for a 2/1/16 Individual Support Plan (ISP) meeting. Individual #7's assessment was completed on 4/19/16. The ISP meeting was held on 5/11/16.
| The program specialist shall provide the assessment to the SC or plan lead, 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). | Assessment Checklist: Checklist to include checking to confirm the assessment is sent 30 days prior to the scheduled meeting. Checklist to be reviewed by staff other then the clients Program Specialist.
See questions and attachment #12 |
10/21/2016
| Implemented |
2390.152(d)(5) | There was no documentation to show that Individual #5's Individual Support Plan (ISP) was sent to the plan team members. | The plan lead shall develop, update and revise the ISP according to the following: Copies of the ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision), shall be provided as required under § 2390.157 (relating to copies). | Copies to will be added to the ISP.
Annual Meeting checklist: Checklist will include ISP sent to plan team members. Rehab Manger will review Annual Checklist. |
10/21/2016
| Implemented |
2390.153(1) | Individual #3¿s 05/29/16 Individual Support Plan (ISP) did not include services provided or outcomes chosen by Individual #3.
Individual #5¿s ISP did not include the outcome action steps for the increased vocational skills outcome.
| The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Services provided to the client and expected outcomes chosen by the client and client's plan team. | ISP Checklist with areas relevant to the vocational environment including services provided to the client and expected outcomes chosen by the client and clients plan team. Checklist will be completed by the Program Specialist and reviewed by the Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.153(3) | Individual #3¿s 5/29/16 Individual Support Plan (ISP) and Individual #5¿s ISP did not include current status of the outcome or a method of evaluation used to determine progress. Individual #6¿s 3/7/16 ISP did not include a method of evaluation used to determine progress. Individual #4's ISP did not include a method of evaluation used to determine progress for the employment outcome.
| The ISP, including annual updates and revisions under § 2390.156 (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. | ISP checklist with areas relevant to the vocational environment including Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. Checklist will be completed by Program Specialist and reviewed by Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.153(4) | Individual #5¿s Individual Support Plan (ISP) does not include supervision needs. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client'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 a higher level of independence. | ISP checklist with areas relevant to the vocational environment including supervision needs. Checklist will be completed by Program Specialist and reviewed by Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.153(5) | Individual #3¿s Individual Supprt Plan (ISP) and Individual #11's ISP did not include his/her social, emotional, environmental needs plan.
| A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | ISP checklist with areas relevant to the vocational environment including social, emotion, environment needs plan. Checklist will be completed by Program Specialist and reviewed by Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.153(7)(i) | Individual #3¿s 05/29/16 Individual Support Plan (ISP) and Individual #5¿s ISP did not include potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: Vocational programming. | ISP checklist with areas relevant to the vocational environment including potential to advance in vocational programming. Checklist will be completed by Program Specialist and reviewed by Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.153(7)(ii) | Individual #3's, #5's, #6's, #10's, and #11's Individual Support Plan did not include potential to advance in competitive employment. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: Assessment of the client's potential to advance in the following: community-integrated employment. | ISP checklist with areas relevant to the vocational environment including potential to advance in community - integrated employment . Checklist will be completed by Program Specialist and reviewed by Rehab Manager.
Request for "relevant" to vocational program requested. (BHSL) |
11/21/2016
| Implemented |
2390.154(a)(1)(iii) | A direct service worker was not present at Individual #3's, #7's, and #11's Individual Support Plan meeting. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2390.156 (relating to ISP review and revision). A plan team must include as its members the following: A direct service worker who works with the client from each provider delivering a service to the client. | Annual Meeting checklist: Included on checklist = Direct Service Worker present at ISP planning meeting. Rehab Manager to review checklist after completion by Program Specialist |
10/21/2016
| Implemented |
2390.156(b) | Individual #10¿s 3/09/16 Individual Support Plan (ISP) review was not signed and dated by the program specialist. | The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP. | Quarterly Meeting checklist: Included on checklist = ISP review signed and dated by Program Specialist. |
10/21/2016
| Implemented |
2390.156(c)(1) | Individual #5's 11/03/15, 02/01/16, 05/16/16, 08/15/16 Individual Support Plan (ISP) reviews did not include progress made towards the increasing vocational skills outcome. | The ISP review must include the following: A review of the monthly documentation of a client's participation and progress during the prior 3 months toward ISP outcomes supported by services provide by the facility licensed under this chapter. | Quarterly Review Check: Progress toward outcomes
See questions with attachment #14 |
10/21/2016
| Implemented |
2390.156(d) | Individual #11¿s 3/18/16 Individual Support Plan (ISP) review was not sent to his/her caseworker. | The program specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Quarterly Meeting checklist: Included on checklist = Date sent |
10/21/2016
| Implemented |