| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.58(a) | REPEAT from 5/11/15: The walls in the exercise room contained many black scuff marks. The program room that was painted purple, contained the same black scuff marks on the walls. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #22 email from D Maurer maintenance Coordinator confirming that work was completed |
09/09/2016
| Implemented |
| 2380.111(c)(4) | Individual #2's physical completed on 2/2/16 did not contain a vision and hearing screening. The field was left blank. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #16 Physical for Individual #3 which includes vision and hearing |
09/09/2016
| Implemented |
| 2380.111(c)(7) | Individual #1's physical completed on 4/12/16 did not include an assessment of their health maintenance needs. The field was left blank. | 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #16 Physical for Individual #3 which includes health maintenance needs |
09/09/2016
| Implemented |
| 2380.122(a) | REPEAT from 5/11/15: Individual #4 was prescribed insulin. The medication label for the insulin indicated to "inject 6 units before breakfast, 8 units at lunch, and 4 units at supper." The medication log indicated the insulin was to be administered 8 units for blood sugar between 70-150, 9 units for 151-200, 10 units for 201-250, 11 units for 251-300, 12 units for 301-350, and 13 units for blood sugar greater than 350 before lunch. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual¿s name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #23 Staff Training Log regarding proper MAR documentation, Attachment #24 MAR for Individual #24,25,26 & 27 Updated MAR for Individual #4, attachment #28 page 1 to 2 with Novolog pharmacy Instructions |
09/09/2016
| Implemented |
| 2380.124(a) | Individual #4 had a sliding scale for insulin administration. His record indicated that for blood sugars over 350 before lunch, staff were to inject 13 units of insulin. On 6/22/16 staff recorded that Individual #4's blood sugar was 421. Individual #4's medication administration record was blank on 6/22/16 in the spot for "inject 13 units for blood sugars over 350 before lunch." Staff indicated that the insulin was administered as prescribed but they did not initial the medication administration record after administration. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #23 Staff Training Log regarding proper MAR documentation, Attachment #24 MAR for Individual #24,25,26 & 27 Updated MAR for Individual #4, attachment #28 page 1 to 2 with Novolog pharmacy Instructions |
09/09/2016
| Implemented |
| 2380.128(e) | The annual practicum forms which contained documentation of the dates and training of medication administration, were not kept for Staff #1. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #21 updated Medication Training for DR dated 7/12/'16 on correct form |
09/09/2016
| Implemented |
| 2380.155(a) | The refrigerator in the program area is for staff and individual use. Individuals store their lunches in the refrigerator. The refrigerator was locked there wasn't a restrictive procedure in place. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #19 sign indicating that consumer property can not be stored in locked areas and attachment #20 staff sign off regarding consumer property |
09/09/2016
| Implemented |
| 2380.172(b) | A staff recorded diet information on Individual #2's 2/2/16 physical. The staff did not date when the entry was made. | Entries in an individual¿s record shall be legible, dated and signed by the person making the entry. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #16 Physical for Individual #3 with additions initialed a nd dated by Heather Keller on 8/29/16 |
09/09/2016
| Implemented |
| 2380.173(1)(ii) | Individual #2's record did not include identifying marks. The field was blank. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #10 Personal Information Page for new intake SF dated 9/12/16, Attachment #11 Updated information on Individual #3 and #12 updated information on Individual #1 |
09/12/2016
| Implemented |
| 2380.173(1)(iii) | Individual #3's record did not include his/her primary language. | Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #10 Personal Information Page for new intake SF dated 9/12/16, Attachment #11 Updated information on Individual #3 and #12 updated information on Individual #1 |
09/12/2016
| Implemented |
| 2380.173(9) | REPEAT from 12/9/15 and 5/11/15: Individual #1's 4/12/16 physical and Individual Support Plan (ISP) indicated that he/she was on a 1400-1700 calorie diet with one supplement daily. His/her 2/18/16 assessment indicated that he/she was to follow a low fat, low cholesterol, low sodium diet. Individual #1's assessment indicated that he/she can not safetly handle hot materials and doesn't allow his/her food to cool. Their ISP indicated that he/she is aware of heat sources. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #13 page from ISP on Individual #14, Physical for Individual #15 and corrected Assessment for Individual #1 initialed and dated 6/29/16 by Heather Keller. Also refer to Attachment # 17 email to Supports Coordinator regarding updated information for individual #1 and attachment #18 updated assessment dated 9/13/16 |
09/09/2016
| Implemented |
| 2380.181(e)(13)(i) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual RT dated 8/5/16 reviewed by Program Manager |
09/09/2016
| Implemented |
| 2380.181(e)(13)(ii) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level in motor and communication 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual RT dated 8/5/16 reviewed by Program Manager includes information on Communication |
09/09/2016
| Implemented |
| 2380.181(e)(13)(iii) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual RT dated 8/5/16 reviewed by Program Manager includes info on Personal Adjustment |
09/09/2016
| Implemented |
| 2380.181(e)(13)(iv) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual #1 dated 8/5/16 reviewed by Program Manager includes information on Socialization |
09/09/2016
| Implemented |
| 2380.181(e)(13)(v) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level in 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual #1 dated 8/5/16 reviewed by Program Manager includes information on recreation |
09/09/2016
| Implemented |
| 2380.181(e)(13)(vi) | REPEAT from 5/11/15: The assessments for Individuals #1 and #2, 2/18/16 and 2/4/16 respepctively, did not contain progress and current level in 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #9 page 1 to 19 Assessment for Individual RT dated 8/5/16 reviewed by Program Manager including information on Community intergration |
09/09/2016
| Implemented |
| 2380.185(b) | REPEAT from 12/9/15: Individual #1's Individual Support Plan (ISP) indicated he/she was prescribed Benadryl as needed for bug bites. Benadryl was not available at the day program. His/Her ISP indicated that he/she was to use a scoop plate, bowl, and adaptive handle utensils at day program. The adaptive equipment was not available at the day program. | The ISP shall be implemented as written. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #5 email to Supports Coordinator regarding adaptive plate, Attachment #6 page from ISP, Attachment #7 MAR for individual #1 and Attachment #8 picture of medication pack |
09/09/2016
| Implemented |
| 2380.186(a) | The program specialist did not complete the Individual's Individual Support Plan (ISP) reviews. A direct support staff completed the reviews. | 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #`2 page 1 to 5 ISP Review for Individual #2 dated 8/5/16 signed by the Program Specialist and reviewed by the Program Manager |
09/09/2016
| Implemented |
| 2380.186(b) | Individual #2 did not sign or date his/her Individual Support Plan (ISP) reviews. Individual #2 had the ability to mark his/her ISP reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | .The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations. Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to Attachment #4 ISP review for Individual #1 signed by that Individual on 9/8/16 |
09/13/2016
| Implemented |
| 2380.186(c)(1) | The Individual Support Plan (ISP) reviews for Individual #1 did not review progress on his/her community activity outcome. | 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. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #4 page 1 to 4 ISP Review for Individual #1dated 9/816 signed by the Program Specialist and reviewed by the Program Manager which includes community activities |
09/09/2016
| Implemented |
| 2380.186(c)(2) | Individual #2's protocol to address his/her social, emotional, and environmental needs was not reviewed on his/her Individual Support Plan (ISP) reviews. The reviews only indicated that staff follow the behavior support plan in the ISP. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The Program Specialist is responsible for ensuring that all documentation is on file, all information is accurate and 2380 regulations are adhered to. At Carlisle Alternatives the Program Manager is responsible to ensure that the Program Specialist has adhered to all regulations Please refer to Attachment # 1 page 1-4 staff training sheet with content of training attached signed by the Program Specialist and Program Manager. Also refer to attachment #4 page 1 to 5 ISP Review for Individual #2 dated 9/5/16 signed by the Program Specialist and reviewed by the Program Manager which includes SEEN Plan |
09/09/2016
| Implemented |