| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(e) | Staff #1 and #2 had fire safety training on 6/17/16 and then again on 6/30/17. | Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Human Resources Coordinator
The Human Resources Coordinator will add an expiration date to Fire Safety Training on the Staff Training Record and will maintain a tickler of each staff's expiration date. The HR Coordinator will ensure that Fire Safety Training is offered within the expiration dates. Staff will be informed of the updated required training policy and disseminate to staff. 2/28/2018 |
01/17/2018
| Implemented |
| 2380.53(a) | Nail Polish was unlocked in the closet in the activities room. No lock on the door in the kitchen that leads to laundry area. Unlocked poisons included bleach, Clorox cleanup, Windex, pinsol, and toilet bowl cleaner. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | 1. The Site Supervisor. The Program Administrator.
The Site Supervisor discarded the nail polish on 1/18/2018. On the Program Administrator contacted Security. On 1/19/2018, Security changed the locked on the door from a butterfly lock to a keyed lock on the laundry room, off the kitchen. 1/22/2018, Housekeeping placed all cleaning supplies into a cabinet in the laundry room and Security put a hasp on the cabinet with a pad lock. On 1/19/2018, the Program Administrator entered a reportable incidents for each individual who was present when unlocked poisons were discovered by the Licensing Representatives.
2. All day program staff will receive re-training on the definitions of neglect and hazardous materials that need to be kept locked. After re-training staff on hazardous materials and keeping them locked, staff will immediately report hazardous materials observed in unlocked areas to management. Management will address the concern immediately. Management will complete a monthly site inspection and checklist to ensure all hazardous materials are kept in locked areas. |
02/23/2018
| Implemented |
| 2380.55(a) | There was a dirty brown yellow sticky stain under the bathroom sink in the blue bathroom. In the cabinet drawers of the blue bathroom contained piles of a dirt like substance. The washroom off of the kitchen area was covered in thick dust. The floors were covered in dirt and debris. There was trash on the floor and the wash basin was filled with dirt and grim. | Clean and sanitary conditions shall be maintained in the facility. | 1. The Program Specialist. The Site Supervisor
Housekeeping was contacted and all areas were cleaned by 2/14/2018.
2. The Site Supervisor will complete a monthly site inspection utilizing the physical site inspection regulations and submit the monthly site inspection to the Program Specialist. 2/28/2018
As needed, the Program Specialist will enter maintenance requests for all areas of noncompliance.
3. The Program Specialist will train the Site Supervisor on completing the monthly site inspection and immediately reporting all safety concerns. 2/23/2018 |
02/23/2018
| Implemented |
| 2380.58(a) | The window in the communication room was cracked the length of the window. There was tape over a hundred pieces on the ceiling of the entire facility. The baseboard, walls, and doors throughout the entire facility were damaged, chipped, marked, and split. In the exercise room below the bulletin board the dry wall was cracked 2 inches running from the baseboard. The blue bathroom shower rod was pulled out of the wall with screws exposed and the rod was bent. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. a. Program Administrator. Day Program Coordinator/Program Specialist. The Site Supervisor.
b. Maintenance Requests were submitted as follows:
Program Specialist: Window ¿ 1/30/2018
Program Administrator: Baseboards, Walls, Doors, Crack in dry wall ¿ 2/17/2018
Program Specialist: Shower Rod ¿ 2/14/2018 ¿ to be completed by 5/1/2018
Tape was removed by the Site Supervisor by 2/15/2018
Window
The maintenance department will remove the broken window and replace it with the new window. 3/16/2018
Baseboards, Walls, Doors, Crack in dry wall
Maintenance will repair damage to baseboards, walls, doors, and the crack in the drywall. Then Maintenance will paint baseboards, walls, and stain doors. 5/1/2018
Shower Rod
The maintenance department will remove the curtain rod and repair the wall. 5/1/2018
2. The Site Supervisor will complete a monthly site inspection utilizing the physical site inspection regulations and submit the monthly site inspection to the Program Specialist. 2/28/2018
As needed, the Program Specialist will enter maintenance requests for all areas of noncompliance.
3. The Program Specialist will train the Site Supervisor on completing the monthly site inspection and immediately reporting all safety concerns. 2/23/2018 |
05/01/2018
| Implemented |
| 2380.63(b) | The screen door off the wash room had a two inch tear. | Screens, windows and doors shall be in good repair. | 1. a. Day Program Coordinator/Program Specialist. The Site Supervisor.
b. A maintenance request was submitted on 2/14/2018 to have replace the screen in the screen door. The screen will be replaced by 2/28/2018
2. The Site Supervisor will complete a monthly site inspection utilizing the physical site inspection regulations and submit the monthly site inspection to the Program Specialist. 2/28/2018
As needed, the Program Specialist will enter maintenance requests for all areas of noncompliance.
3. The Program Specialist will train the Site Supervisor on completing the monthly site inspection and immediately reporting all safety concerns. 2/23/2018 |
02/28/2018
| Implemented |
| 2380.67(a) | The cabinet by the fireplace was missing the right handle and the cabinet in the blue bathroom was missing all knobs. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. a. Day Program Coordinator/Program Specialist. The Site Supervisor.
b. A maintenance request was submitted on 2/14/2018 to have to replace the missing handle on the cabinet by the fireplace and to have knobs replaced in the blue bathroom. The cabinet handle and the knobs in the blue bathroom will be replaced by 3/16/2018.
2. The Site Supervisor will complete a monthly site inspection utilizing the physical site inspection regulations and submit the monthly site inspection to the Program Specialist. 2/28/2018
As needed, the Program Specialist will enter maintenance requests for all areas of noncompliance.
3. The Program Specialist will train the Site Supervisor on completing the monthly site inspection and immediately reporting all safety concerns. 2/23/2018 |
02/23/2018
| Implemented |
| 2380.72(b) | There were leaves and trash piled about three inches on the back porch near the door. | The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. a. Day Program Coordinator/Program Specialist. The Site Supervisor.
b. A maintenance request was submitted on 1/30/2018 to have leaves and trash removed from the back porch near the door. On 1/31/2018, the Maintenance department cleared the leaves and trash.
2. The Site Supervisor will complete a monthly site inspection utilizing the physical site inspection regulations and submit the monthly site inspection to the Program Specialist. 2/28/2018
As needed, the Program Specialist will enter maintenance requests for all areas of noncompliance.
3. The Program Specialist will train the Site Supervisor on completing the monthly site inspection and immediately reporting all safety concerns. 2/23/2018 |
02/23/2018
| Implemented |
| 2380.111(c)(7) | Individual #2's physical dated 6/27/17 did not contain health maintence needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 1. a. The Nurse Manager. Day Program Coordinator/Program Specialist.
b. The Nurse Manager will add to the physical form a new section entitled Health Maintenance Needs by 2/23/2018
2. The Nurse Manager or designee will review the physical form upon return from the appointment to ensure the section has been completed. If it was not completed, the Nurse Manager or the Medical Coordinator will contact the physician for the information.
The Day Program Coordinator/Program Specialist will review the individual¿s physical exam upon receipt to ensure the health maintenance section is completed. Training regarding new procedure will be completed by 2/23/2018. |
02/23/2018
| Implemented |
| 2380.176(a) | -- Individual records containing confidential information were left unlocked on a shelf by the front door. | Individual records shall be kept locked when they are unattended. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: A cabinet with a key lock was purchased for the purpose of securing the individuals records at day program.
2. A Procedure for obtaining consent to release information was written on 2/17/18. Staff will be trained on the procedure on 2/23/18. |
02/23/2018
| Implemented |
| 2380.177 | There was no consent to release information in Individual #1 and #2's record. | Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist compiled a form on 2/17/18 for the release of information. The Day Program Coordinator/Program Specialist will meet with the day program participants to complete the form. Completion of the form for individuals #1 and #2 is to be completed by 2/23/18.
2. A Procedure for obtaining consent to release information was written on 2/17/18. |
02/23/2018
| Implemented |
| 2380.181(c) | Individual #1 and #2 assessment did not contain basis of assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1 and Individual #2. The annual assessment for Individual #1 and for Individual #2 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains a basis of assessment.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(1) | Individual #2's assessment dated 10/16/17 did not contain strengths and needs. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #2. The annual assessment for Individual #2 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains strengths and needs.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(5) | Individual #2's assessment dated 10/16/17 did not include the ability to self-administer. | The assessment must include the following information: The individual¿s ability to self-administer medications. | 1. a. Day Program Coordinator/Program Specialist is responsible
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #2. The annual assessment for Individual #2 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains the ability to self-administer medications.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(7) | Individual #1 and #2 assessment did not include the ability to move away from heat sources. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1 and Individual #2. The annual assessment for Individual #1 and individual #2 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains the ability to move away from heat sources.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual #1's assessment dated 7/14/17 did not contain progress and growth for 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. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for Health.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's assessment dated 7/14/17 did not contain progress and growth 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. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for motor and communication.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's assessment dated 7/14/17 did not contain progress and growth for 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. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for personal adjustment.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's assessment dated 7/14/17 did not contain progress and growth for 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. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for Socialization.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(v) | -- Individual #1's assessment dated 7/14/17 did not contain progress and growth for 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. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for Recreation.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's assessment dated 7/14/17 did not contain progress and growth for 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. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist with input from FOCUS staff and through direct observation has completed an Adaptive Behavior Scale for Individual #1. The annual assessment for Individual #1 was revised and the new assessment was sent to the individual and to team members. The revised assessment contains progress and growth for community integration.
2. A Procedure for Writing the Annual Assessment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.183(7)(i) | -- Individual #1 and #2's ISP did not include the assessment of the individual potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist emailed the SC for Individual #1 and the SC for Individual #2 giving notice that the ISP did not include the assessment of the individual potential to advance in vocational programming and a summary of the day programs assessment of the individual potential to advance in vocational programming.
2. A Procedure for inclusion of the assessment of the individual potential to advance in vocational programming was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.183(7)(iii) | Individual #1 and #2's ISP did not include the assessment of the individual potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (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. a. Day Program Coordinator/Program
b. Correction: Day Program Coordinator/Program Specialist emailed the SC for Individual #1 and the SC for Individual #2 giving notice that the ISP did not include the assessment of the individual potential to advance in competitive community integrated employment and a summary of the day programs assessment of the individual potential to advance in competitive community integrated employment.
2. A Procedure for inclusion of the assessment of the individual potential to advance in competitive community integrated employment was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.186(a) | Individual #1's ISP reviews were not completed for June, September, and December 2017. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist has changed the ISP Review format for Individual #1¿s ISP Reviews to better reflect the Progress towards ISP Outcomes. Reviews for June (5/29/17), September (8/29/17) and December (11/29/17) were re-created using the new format. Day Program Coordinator/Program Specialist will review the reviews with Individual #1 by 2/23/18 and will send the reviews to Individual #1's team members
2. A Procedure for Quarterly Report Reviews was written on 2/17/18 and the Day Program Coordinator/Program Specialist will train staff to the procedure. |
02/23/2018
| Implemented |
| 2380.186(c)(1) | Individual #1's monthly reports do not address the ISP outcomes. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist has changed the ISP Review format for Individual #1¿s Monthly Reports to better reflect the Progress towards ISP Outcomes.
2. A Procedure for Monthly Report Reviews was written on 2/16/18 and the Day Program Coordinator/Program Specialist will train staff to the procedure and to the new monthly report format on 2/23/18. |
02/23/2018
| Implemented |
| 2380.186(e) | Individual #1 and #2 record did not include the option to decline the ISP review | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Day Program Coordinator/Program Specialist has sent correspondence to team members notifying them of the option to decline the ISP Reviews.
2. A Procedure for the Option to Decline the ISP Reviews was written on 2/17/18. |
02/17/2018
| Implemented |
| 2380.188(a) | Individual #1's record did not contain a seizure protocol. | The facility shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | 1. a. Day Program Coordinator/Program Specialist
b. Correction: Seizure Protocols will be part of the records for individuals with Seizure Disorders. Staff will be trained for seizure protocols
c. Day Program Coordinator/Program Specialist has trained staff to Seizure Protocol for Individual #1 on 2/15/2018.
Day Program Coordinator/Program Specialist has reviewed the medical records for all individuals at the day program and in addition to Individual #1, 6 other individuals are diagnosed with a seizure disorder or history of seizure disorder. Seizure Protocols have been compiled for each individual with a seizure disorder or history of seizure disorder. Staff will be trained by 2/23/2018.
2. A Procedure for Seizure Protocol was written on 2/16/18 and the Day Program Coordinator/Program Specialist will train staff to the procedure and completion of the Seizure Record on 2/23/18. |
02/23/2018
| Implemented |