| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff # 1's fire safety training dated 10/02/2015 was not conducted by a fire safety expert.
Staff # 2's fire safety training dated 10/02/2015 was not conducted by a fire safety expert.
| Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | To correct this going forward, a fire safety expert was brought in on 4/7/16 to provide training to staff who will be conducting future fire safety trainings (see attached). This ensures future fire safety trainings will be done by an expert. (A record review of all staff will be completed within 30 days of receipt of this plan in order to identify any other staff out of compliance. Any staff found to be out of compliance will be trained within 15 days DS 08/01/2016) |
04/07/2016
| Implemented |
| 6400.163(c) | Individual # 1's previous psychological evaluation occurred on 07/15/2015 and the most recent psychological evaluation occurred on 01/12/2016. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The gap in psychiatric services occurred due to a documented absence of the existing psychiatrist and the inability to secure the services of a replacement psychiatrist (see attached). As of licensing, a new psychiatrist had been secured and psychiatric appointments were being scheduled within the 90 day time frame. (a record review of all individuals being served will be completed within 30 days of receipt of this plan in order to identify any other individual records out of compliance. Any individuals found out of compliance with be scheduled for a review within 15 days DS 08/01/2016) |
01/12/2016
| Implemented |
| 6400.181(d) | Individual # 1's annual assessment dated 07/20/2015 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | A cover page has been added to the existing Assessment which provides a line for signature (see attached). NHS is in the process of altering the electronic form to include a line for signature. (The program specialists will be retrain in their job duties and a record review of all individuals being served will be completed in 30 days of receipt if this plan to identify any other individuals out of compliance. Any assessments found to be out of compliance will be signed and dated by the program specialist.) |
04/04/2016
| Implemented |
| 6400.181(f) | There was no documentation Individual #1's annual assessment dated 07/20/2015 was sent to the SC and team members prior to the ISP meeting date of 09/03/2015. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| A Date of Dissemination has been added to the cover sheet to the Assessment (see attached). NHS is working to ensure the electronic form contains a date of dissemination as well. (The program specialists will be retrained in their job duties and a record review of all individual served will be completed within 30 days of receipt of this plan. If an assessment was not sent to team members in accordance to the time frame, the program specialist will immediately send it. A tracking system will be developed to ensure assessments at being sent to team members according to the timeframes identified in the regulations DS 08/01/2016) |
04/04/2016
| Implemented |
| 6400.185(a) | Individual #1's 3 month ISP review documentation covering the period from 10/31/2014-02/02/2015 was not implemented by the ISP date of 11/05/2014. | The ISP shall be implemented by the ISP's start date. | The previous system of counting 90 days in between Quarterly Reviews has been abandoned in favor of a new system of counting 3 months (i.e. 1/15/16 ¿ 4/15/16) therefore ensuring that all 3 month review documentation is implemented by the ISP start date. All 365 days of the year are covered.(The program specialists will be retrained in their job duties and a record review of all individuals served will be completed within 30 days of receipt of this plan. Any individual three months ISP review documentation found out of compliance with be correct within 15 days. A tracking system will be developed to ensure the three month ISP reviews follow the individual's ISP annual review update date. DS 08/01/2016) |
04/06/2016
| Implemented |