Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.89(d) | There were 2 failed fire drills in February. On 2/6/2019 and 2/7/2019, Individual #4 refused to evacuate during both fire drills. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Operations Director and Day Program Specialist met with Individual #4 to discuss the importance of exiting the building during a fire drill. Fire safety materials were reviewed with individual #4. one time monthly program specialist will conduct a mock fire drill for individual #4 and document his progress. |
03/14/2019
| Implemented |
2380.111(c)(1) | This section was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: A review of previous medical history. | A review of previous medical history has been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.111(c)(4) | Hearing screening was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Hearing screening has been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books. This physical examination includes Vision and hearing screening |
04/03/2019
| Implemented |
2380.111(c)(7) | All 3 of these areas were blank on Individual #3's physical exam dated 2/9/2019. | 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. | Assessment of the individuals health and maintenance needs, medication regimen and the need for blood work at recommended intervals have been completed on individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.111(c)(8) | This section was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: Physical limitations of the individual. | Physical Limitations has been added to Individual # 3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.111(c)(9) | This section was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: Allergies or contraindicated medication. | Allergies and contraindicated medications have been added to Individual#3 Physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.111(c)(10) | This section was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Medical information pertinent to diagnosis and treatment in case of an emergency has been completed on individual #3 physical form. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.111(c)(11) | This section was blank on Individual #3's physical exam dated 2/9/2019. | The physical examination shall include: Special instructions for an individual's diet. | Special Instructions for Individual's has been added to the physical. Operations Director will review all consumer physicals to ensure the form is compliant. Once the form has been reviewed it will be filed in consumers books |
04/03/2019
| Implemented |
2380.181(e)(13)(i) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Day Program Operations Director has updated Individual #1, Individual #2, and Individual #3 skills assessments to include section "Progress during past year" . Director also updated section documentation of disability which includes current disability, diagnosis and medical limitations.
((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) |
03/05/2019
| Implemented |
2380.181(e)(13)(ii) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Progress and Growth section has been currently updated for Individual #1, Individual #2, and Individual #3. All motor and communication skills have been updated on skills assessments |
03/08/2019
| Implemented |
2380.181(e)(13)(iii) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Assessment has been updated to reflect the following section : Personal Adjustment. Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Personal Adjustment.
((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) |
03/08/2019
| Implemented |
2380.181(e)(13)(iv) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Assessment has been updated to reflect the following section : Socialization. Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Socialization..
((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) |
03/08/2019
| Implemented |
2380.181(e)(13)(v) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Assessment has been updated to reflect the following section : Recreation Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Recreation.
((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) |
03/08/2019
| Implemented |
2380.181(e)(13)(vi) | Progress & growth in this area was not assessed on Individual #1's assessment dated 9/13/2018, Individual #2's assessment dated 9/13/2018, and Individual #3's assessment dated 5/7/2018. | 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. | Assessment has been updated to reflect the following section : Community Integration Individual #1, Individual #2 and Individual # 3 skills assessment now shows progress over 365 days for Community Integration.
((Program Specialist will review all assessments to ensure compliance by 5/31/19 -CH 4/11/19)) |
03/08/2019
| Implemented |