| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | No notification letter was sent to the local fire department. Individual #1 residing in this home requires assistance to evacuate. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Our Notification Letter format has been updated to reflect the recommendations made by licensing representatives. This form was reviewed with Program Specialists on 12/8/16 and immediately used. Program Specialists updated the Notification Letter for the individual in this home. An additional review of records was completed. It was determined that consumer MH needed updated as well. See attachments for the two updated letters utilizing the new letter format (15 and 2). |
12/20/2016
| Implemented |
| 6400.181(b) | Individual #1's assessment dated 5/12/16 was not updated to include a change in supervision needs. Individual #1's supervision was changed in July 2016 to be 2:1 staff for a minimum of three days after visits with family due to increased aggression. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | The change in staffing was the result of approved supplemental habilitation request which was updated in the plan. However, the Program Specialist did not recognize the need for assessment update. This was IFC¿s first Supplemental Habilitation request. Individual 1¿s assessment has been updated to include this change. During our debrief on 12/8/16, we reviewed the non-compliance and regulation as it relates to services including supplemental habilitation to insure that updates will be completed appropriately moving forward. See attachments for updated assessment (13) and additional plan and assessment completed since survey that is compliant (14). |
12/30/2016
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) updated 7/29/16 did not include his/her potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (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.
| Program Specialist has completed updates to individual 1¿s plan and has submitted these to the SC for inclusion in the plan. A review of individual records was completed by PS and no other non-compliances were found. ISPs updates are reviewed prior to submission to insure ongoing compliance by PS Supervisor. See attachments for correspondence (10), ISP update (11), and another plan (12) done in compliance since last licensing survey. |
12/30/2016
| Implemented |