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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | Program Specialist #1, date of hire, 2/27/17, did not have the educational qualifications required for the program specialist position. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | The program specialist responsible for the cite was terminated on 8/6/18. During the inspection review of the required qualifications, the diploma submitted by this former employee was questioned. Utilizing the requirements listed in 6400.44(c), the Human Resources Director initiated a policy and procedure ¿Employment Educational Requirement Verification¿. Once one of the requirements required by the regulation are met, a Human Resource assistant will research the validity of the applicants documentation by one of the following: request of an official transcript, contact registrar¿s office for confirmation of applicant attending and completing degree, and contacting previous place(s) of employment to verify the applicant has worked there and the length of employment. Only after verification, the applicant will be given an approved job offer. The information gleaned from the above process will be placed in the employee¿s permanent file. Interviews are being conducted at this time for a new program specialist. Once the process of verification is completed, a copy will be retained with the documentation from this plan of correction. The human resource department is in the process of verifying the validity of all 8 remaining program specialists. |
08/29/2018
| Implemented |
| 6400.186(b) | Individual #1's ISP review for the review period from 7/1/17 to 9/30/17 was not signed by Individual #1. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Each program specialists (4) within the western region were retrained on regulation 6400.186(b) by the Western Region Operations Director on 8/23/18. This training included responsibility to review the document with the individual and have the individual sign it. This is completed prior to submission to the team. The program specialist responsible for the cite was terminated on 8/6/18. Interviews are being conducted at this time for a new program specialist. Once hired, the replacement program specialist will be trained by the Western Region Operations Director and her Associate on the position, including the job duties relating to this regulation. The sign in sheet and outline from this training are kept at the main office. All four program specialists have submitted their next ISP review with the signatures and dates for review by the Quality Assurance Director for compliance. To ensure no further infractions occur, the Quality Assurance Associate assigned to the region will complete 2-3 inspections at the homes in the region monthly, where she will spend two days reviewing the chart of one of the individuals, along with the other 6400 regulations for the site in general. This schedule will ensure each home is reviewed twice each year. The report will be compiled and submitted to the program manager, program specialist, and operations director for acknowledgment and corrective actions to each cite, if any were found. The Quality Assurance Director will follow up with the home 2 months after the inspection to review the cited issues for compliance. This process will begin 9/1/18, and will be an ongoing process within the Quality Assurance Department. |
08/29/2018
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.171 | On 8-11-15 at 9:15 AM, a bag of lettuce was open in the refrigerator and a bag of beer batter fish filets was open in the freezer. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Valley Community Services will ensure food is protected from contamination while being stored, prepared, transported and served. The Quality Assurance Director will retrain the program managers on this regulations by September 18, 2015. To ensure no further infractions occur, the program manager will complete a monthly monitoring tool and the operations director will complete a quarterly monitoring tool, which will be submitted to the Quality Assurance Department for tracking. |
09/06/2015
| Implemented |
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