| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Closet by AED has laundry detergent and windsheild washer fluid and is not locked. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The Program Supervisors were trained on the regulation (Attachment #27). The Program Supervisor has posted a sign on the closet door (Attachment #28) and has also requested that maintenance put a hasp on the door so that it can be locked with a master lock (Attachment #29). |
01/15/2015
| Implemented |
| 2380.113(a) | Staff #5's physical was on 11/15/2010 and then again on 12/11/2012. It was not completed in the regulated time frame. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Program Supervisors were trained on the regulation (Attachment #25). The current physical for Staff #5 shows that her current physical is in compliance; the physical was completed on 12/7/2014 and her tb test was read on 12/10/2014 (Attachment #26). |
12/22/2014
| Implemented |
| 2380.173(1)(i) | Individaul #3's record did not include her admission date into the program. | Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number. | The Program Supervisors were trained on the regulation (Attachment #19). The Personal information form for Individual #3 was updated to include her admission date into the program (Attachment #20). All records reviewed for compliance. |
12/22/2014
| Implemented |
| 2380.173(1)(ii) | Individual #3's record did not include any identifying marks. | 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 Supervisors were trained on the regulation (Attachment #21) The Personal information form for Individual #3 was updated to include any identifying marks (Attachment #20). All records reveiwed for complianc. |
12/22/2014
| Implemented |
| 2380.173(1)(iv) | Individual #3's record did not include religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The Program Supervisors were trained on the regulation (Attachment #22). The Personal information form for individual #3 was updated to include religious affiliation (Attachment #20). All records reviewed for compliance. |
12/22/2014
| Implemented |
| 2380.173(9) | Individual #1's ISP states she has no paticular diet but should limit coffee and chocolate. Her physical states she should have a heart healthy diet. Individual #3's ISP list no allergies. Her physical states she is allergic to sulfa and decovac. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program Supervisors were trained on the regulation (Attachment #23) Program Supervisor emailed the Supports Coordinator for individual #1 and #3 to correct content discrepancies between the physical and ISP (Attachment #24). The updated sections of the IPS will be forwarded once updated by the Supports Coordinator. All records were reviewed for any other content discrepancies. |
02/01/2015
| Implemented |
| 2380.181(e)(13)(i) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #12). The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Health (Attachment #13) All other records were reviewed to check for compliance. |
12/22/2014
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #14) The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Motor and Communication Skills (Attachment #13). All other records were reviewed for compliance. |
12/15/2014
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #15) The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Personal Adjustment (Attachment #13).All othr ecords were reviewed for compliance. |
12/15/2014
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #16) The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Socialization (Attachment #13). all other records were reviewed for compliance. |
12/15/2014
| Implemented |
| 2380.181(e)(13)(v) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #17) The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Recreation (Attachment #13). All other records were reviewed for compliance. |
12/22/2014
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1, #2, and #3's assessment did not include progress over the last 365 calendar days 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 Supervisors were trained on the regulation (Attachment #18) The progress and growth section of the assessment for Individual #1, #2 and #3 were revised to show the progress over the last 365 days and the current level in the area of Community Integration (Attachment #13). All other records were reviewed for compliance. |
12/22/2014
| Implemented |
| 2380.183(5) | Individual #1's takes Benzotropine and Haldol for anxiety but does not have a SEEN plan in the record. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | The Program Supervisors were trained on the regulation (Attachment #2) The SEEN plan for Individual #1 is now part of the record. The SEEN plan is attached (Attachment #3). All records were reviewed for indvidiuals that should have SEEN plans. |
12/22/2014
| Implemented |
| 2380.183(7)(i) | Individual #1, #2, and #3's ISP did not include 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. | The Program Supervisors were trained on the regulation (Attachment #4). The vocational information section of the ISP for individual #1 is attached (Attachment #5) The Program Supervisor has emailed the Supports Coordinators for individual #2 and #3 and request the vocational information section be updated for both individuals and sent a copy of that page of our assessment (Attachment # 6 and Attachment #7). This information will be forwarded when the ISP is updated. All ISP's were reviewed for vocational potential. |
02/01/2015
| Implemented |
| 2380.183(7)(iii) | Individual #1, #2, and #3's ISP did not include 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. | The Program Supervisors were trained on the regulation (Attachment #8). The employment/volunteer information section of the ISP for individual #1 and #2 is attached (Attachment #9 and Attachment #10). The Program Supervisor has emailed the Supports Coordinators for individual #3 to request the employment/volunteer information section be updated for both individuals (Attachment #11). This information will be forwarded when the ISP is updated. All other ISPs were reviewed for compliance. |
02/01/2015
| Implemented |
| 2380.186(c)(2) | Individual #1 ISP reviews did not review their SEEN plan. | 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 Supervisors were trained on the regulation (Attachment #1). Individual #1 has an ISP review on 1/15/15, after which a copy of the review will be forwarded to show that the SEEN plan for her is being reviewed. All other records reviewed for compliance. |
01/15/2015
| Implemented |