Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.103 | The written evaucation plan did not include individual responsibilities in the event of an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Administrative Coordinator revised the written evacuation plan to include individual responsibilities in the event of an emergency on 6/3/16, see attachment, (5th Street. #1). The Administrative Coordinator revised Emergency Evacuation Plans for 15 homes on 6/3/16, see attachment (6th Street #2). The Director/Manager will review with individuals their responsibilities on the revised evacuation plan by 7/30/16, (attachment 5th St. #3). |
07/30/2016
| Implemented |
6400.181(e)(13)(ii) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in motor and communication skills. This section contained the same information as the previous 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: Motor and communication skills. | On 6/6/16, the Director revised Individual #1's assessment to include a change in her motor and communication skills, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(iii) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in residential living. This section contained the same information as the previous 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. | On 6/6/16, the Director revised Individual #1's assessment to include a change in residential living, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(iv) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in personal adjustment. This section contained the same information as the previous 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. | On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in personal adjustment, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(v) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in socialization. This section contained the same information as the previous 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: Socialization. | On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in socialization, attachment (5th St, #2). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(vi) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in recreation. This section contained the same information as the previous 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: Recreation. | On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in recreation, attachment (5th St, #2). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(viii) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in managing personal property. This section contained the same information as the previous 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: Managing personal property. | On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in managing personal property, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.181(e)(13)(ix) | Individual #1's 8/14/15 assessment did not include progress or regression over the past year in community integration. This section contained the same information as the previous 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: Community-integration. | On 6/6/16, the Director revised Individual #1's assessment to include progress or regression over the past year in community integration, attachment (5th St, #2 ). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/06/2016
| Implemented |
6400.185(b) | Individual #1's Individual Support Plan (ISP) indicates progress is being made when Individual #1 controls his/her anger with less than 20 displayed instances to decrease monthly once goal is met. This information is not being tracked or reported on Individual #1's ISP reviews or monthly documemation. | The ISP shall be implemented as written. | On 5/13/16 Program Director reviewed with Habilitation Manager the documentation requirements of Individual #1's relationship outcome, attachment (5th St, #7). Habilitation Manager reviewed with staff the documentation requirements of Individual #1's relationship outcome, attachment (5th St. #8). |
05/13/2016
| Implemented |
6400.186(c)(2) | Individual #1's 3/21/16, 12/17/15, 9/18/15, and 6/8/15 Individual Support Plan (ISP) reviews did not provide an update on the social, emotional, environmental needs plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | On 6/2/16 Assistant Vice President trained Program Directors on Regulation 186(c)(2), attachment (3rd Ave #9). Program Director will include an update on Individual #1's social, emotional, environmental needs plan on the next ISP review due 6/17/16, attachment (5th St., # 6). |
06/30/2016
| Implemented |
6400.213(11) | Individual #1's Individual Support Plan (ISP) indicated he/she is able to have 8 hours of alone time at home and 7 hours of alone time in the community. The 8/14/15 assessment indicated he/she is able to have 7 hours of alone time. The supervision plan indicated he/she is able to have 7 hours of alone time in the home or in the community. The 3/17/16 ISP review indicated he/she is able to have 7 hours of alone time. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | On 6/6/16 Program Director revised Individual #1's assessment to be consistent with the ISP, attachment (5th St. #2). On 6/6/16 Program Director revised Individual #1's supervision plan to be consistent with ISP and assessment, attachment (5th St. #5). On 6/2/16 Assistant Vice President trained Program Directors on Regulation 213(11), attachment (3rd Ave #9). |
06/06/2016
| Implemented |