| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(a) | Individual #1 date of admission to the facility was 1/30/19 and the assessment was not completed until 4/5/19. This is outside of the regulatory timeframe to have an initial assessment completed within 1 year prior to or 60 calendar days after admission to the residential home. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | I have reviewed the 6400 regulations regarding the Program Specialist responsibilities and requirements in reference to the ISP and Assessment time frames.
The date of the assessment is documented in an Excel document that has all due dates, in which the Program Specialist needs to be aware. The Program Specialist will check this document weekly to make sure that due dates are honored. There was no 60-day assessment that was needed to be sent out since licensing. So, the attached assessment is an annual assessment that was sent out on time. |
07/11/2019
| Implemented |
| 6400.181(e)(4) | Individual #1 4/5/19 assessment does not address supervision needs regarding unsupervised time at home and in the community. The individual's assessment documents that the individual is "able to be unsupervised for long periods of time," "can be left alone without someone checking on the individual during awake hours for indefinite periods of time," can remain alone in the home overnight," "and requires intermittent supports with transportation to medical appointments" for supervision at home. However, this does not define the amount of time the individual can be left unsupervised at any given day. The assessment also does not define the amount of unsupervised time in the community. According to the assessment, "the individual is able to be in the community independently. There is not a required amount of supervision hours." | The assessment must include the following information: The individual's need for supervision.
| I have reviewed the 6400 regulations regarding the supervision requirements for individuals. To avoid this in the future, we will make sure that all individuals have a specified time listed in the ISP and assessment that states how much supervision the individual needs. The staff has been trained on the new supervision plan.
On 7/8/19, the Program Specialist emailed an Assessment Addendum to the team, which included the new supervision plan that states that staff will check in with the individual once in the morning and once at night. Attached is the emailed Assessment Addendum, with the supervision plan. A copy was mailed to one team member that did not have an email address. |
07/08/2019
| Implemented |
| 6400.183(4) | Individual #1 Individual Support Plan (ISP) did not include the amount of time the individual is able to be unsupervised at home or in the community. As defined under 6400.181(e)(4), the individual's assessment also does not include the amount of unsupervised time the individual is allotted at home or in the community. It was defined as "the individual lives semi-independently and can be left alone without someone checking on her during awake hours, for indefinite periods of time." | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | I have reviewed the 6400 regulations regarding the supervision requirements for individuals. To avoid this in the future, we will make sure that all individuals have a specified time listed in the ISP that states how much supervision the individual needs. The staff has been trained on the new supervision plan.
Attached are two emails. The first is the email requesting a meeting with the Supports Coordinator, the individual, and the Program Supervisor. The meeting was held on 7/5/19, and it was decided that staff will check in with the individual once in the morning and once at night. The second email is an email from the Supports Coordinator saying the ISP was updated. |
07/05/2019
| Implemented |
| 6400.213(11) | Individual #1 2/6/19 physical examination form and identification sheet in the record, both recorded allergies to be, Cetylpyridinium, Benzocaine, Penicillin/Cephalosporins, Menthol, Morphine, seasonal allergies, can not take any medications containing NSAIDs including Advil, Tylenol, Cough syrup, etc. due to Naproxen. The individual's Individual Support Plan (ISP) only documented allergies to include seasonal allergies, Penicillin, Morphine, Menthol, and that the individual cannot take any medications containing NSAIDS including Advil, Tylenol, cough syrup etc. due to Naproxen. According to the individual's record, the agency program specialist did not notify the individual's supports coordinator of the additional allergies until 6/19/19, the second day of their annual inspection. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | I reviewed the 6400 regulations in regards to the ISP and content discrepancy. To avoid this happening in the future, The Program Specialist created a document that lists what documents need to have matching information. That way if something is updated then it is known what other documents need to be updated.
The Supports Coordinator was contacted on 6/19/19 and informed about the discrepancy. It was requested that the allergies be updated to match the physical and information sheet. On 6/19/19, the Supports Coordinator updated the ISP. |
06/19/2019
| Implemented |