Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.181(b) | Individual #1's 5/11/16 assessment has not been revised to include locking of sharps in his home due to his threatening to do harm to self/others. | 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. | VCS will ensure recommendations are made to revise a service or outcome and have an assessment completed. Individual #1 in the past had threatened to harm himself with a knife. VCS received Human Right approval to lock sharps in his home due to this incident, and a fade plan was implemented. The program specialist will complete an addendum regarding the locking of sharps and will send to all team members, including the supports coordinator. It will be placed in the permanent chart. This will be completed and sent to the program director for verification prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(b) prior to September 30, 2016. The program director and operations director will randomly review monthly the health and safety issues in the ISP and ensure they are accurate and followed. Additionally, the quality assurance department will randomly monitor compliance on a monthly basis. |
10/14/2016
| Implemented |
6400.181(e)(6) | Individual #1's May 2016 assessment does not clearly state if poisons need to be locked in his home or not. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | VCS will ensure assessments include the individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. ISP. Individual #1 understands precautions and would independently avoid poisonous/dangerous substances and would not ingest them. The program specialist will complete an addendum regarding poisons/dangerous substances and will send to all team members. It will be placed in the permanent chart. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(6) prior to September 30, 2016. The program director and operations director will randomly review monthly the health and safety issues in the ISP and ensure they are accurate and followed. Additionally, the quality assurance department will randomly monitor compliance on a monthly basis. |
10/14/2016
| Implemented |
6400.181(e)(10) | Individual #1's May 2016 assessment was not a part of his lifetime medical history and was not sent to team members. | The assessment must include the following information: A lifetime medical history. | VCS will ensure the assessment includes a lifetime medical history. Individual #1 lifetime medical history will be sent to the team, including the supports coordinator prior to October 14, 2016. This email will be placed in the permanent file. The program director will retrain the program specialists on 6400.181(10), and each program specialist will review the attachments sent with the current summary of assessment. If the lifetime medical history, and other current assessment were not attached, they will submit the appropriate documentation to all team members and place the email in the permanent chart. This training will be completed prior to September 30, 2016. To ensure no further infractions occur, program specialists will email their assessment letter, including the attachments, to the program director, starting October 1, 2016 and ending December 31, 2016. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
09/30/2016
| Implemented |
6400.181(e)(13)(i) | Individual#1's May 2016 assessment has no noted progress and growth. He has many health issues this past year and medication changes. None of this information was contained in his assessment. | 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.
| VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of health. The program specialist will attach an addendum to the May 2016 assessment with accurate and detailed information regarding Individual #1 health. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(ii) | No progress and growth noted for individual #1. | 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. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of motor and communication skills. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 motor and communication skills. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(iii) | No progress and growth noted for individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of activities of residential living. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 activities of residential living. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(iv) | No progress and growth noted for individual #1. | 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. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of personal adjustment. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 personal adjustment. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(v) | No progress and growth noted for individual #1. | 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. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of socialization. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 socialization. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(vi) | No progress and growth noted for individual #1. | 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. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of recreation. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 recreation. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(vii) | No progress and growth noted for individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of financial independence. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 financial independence. This will be completed prior to October 15, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(e)(13)(ix) | No progress and growth noted for individual #1. | 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. | VCS will ensure assessments include information regarding the individual¿s progress over the last 365 day and current level in the area of community integration. The program specialist will attach an addendum to the May 2016 assessment adding more detailed information regarding Individual #1 community integration. This will be completed prior to October 14, 2016. The program director will retrain the program specialists on 6400.181(13)(i) prior to September 30, 2016. To ensure no further infractions occur, each program specialist will be required to submit assessments to the program director starting October 1, 2016 and ending December 31, 2016 for approval. Additionally, the quality assurance department will randomly review the assessment on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.181(f) | A copy of individual #1's current assessment was not given to guardian. | (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).
| VCS will ensure program specialists provide assessment to the plan team members within 30 calendar days after the ISP review meeting. The program specialist will send Individual #1 May 2016 assessment to his guardian, and will forward this to the program director for verification. The program director, along with the quality assurance director will retrain the program specialists on 6400.181(f) prior to September 30, 2016. Program specialists, along with the program managers will submit a list of team members for each individual residing in the home to the quality assurance department. Approval will be forwarded and the program specialist will submit an ISP correction form, if necessary, to the supports coordinator. This email will be placed in the individual¿s permanent book. The program specialist will ensure that all team members, who have not decline documentation are added to all appropriate documentation, including assessments. All charts will be updated prior to October 31, 2016. To ensure no further infractions occur, the program director will randomly monitor the documentation on a monthly basis. Additionally, the quality assurance department will also randomly monitor compliance on a monthly basis. |
10/31/2016
| Implemented |
6400.183(5) | Individual #1 takes medication to treat psychosis, anxiety, and depression. His ISP does not include his SEEP plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | VCS will ensure the ISP includes a protocol to address the social, emotional and environmental needs of the individual, including any psychotropic medications. Individual #1 SEE plan will be written and sent via email to the supports coordinator by October 14, 2016 and a copy of the email will be placed in the permanent chart. The program director will retrain program specialists on 6400.183(5) prior to September 30, 2016. To ensure no further infractions occur, the program director will randomly review ISP for compliance on a monthly basis. Additionally, the quality assurance department will also randomly review ISP on a monthly basis for compliance. |
10/14/2016
| Implemented |
6400.186(c)(2) | Individual #1's ISP reviews 7/8/16, 4/15/16, 1/5/16, and 10/3/15 did not review his dental hygiene plan, his SEEP plan, and his Behavioral Support plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | VCS will ensure ISP reviews include the review of each section of the ISP specific to the residential home. Individual #1 will have his dental hygiene plan, his SEE plan, and behavior support plan addressed in his ISP review ending on October 8, 2016. The program specialist will submit the completed ISP review to the program director for approval. The program director will retrain the program specialists on 6400.186(c)(2) prior to September 30, 2016. To ensure no further infractions occur, program specialists will submit ISP reviews to the program director starting October 1, 2016 and ending December 31, 2016. Additionally, the quality assurance department will randomly monitor compliance on a monthly basis. |
10/08/2016
| Implemented |
6400.186(d) | Individual #1's guardian, did not receive copies of the ISP reviews 10/3/15, 1/5/16, 4/15/16, and 7/8/16. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | VCS will ensure program specialists provide ISP review documentation to the plan team members within 30 calendar days after the ISP review meeting. The program specialist will send Individual #1 October 8, 2016 ISP review to his guardian, and will forward this to the program director for verification. The program director, along with the quality assurance director will retrain the program specialists on 6400.186(d) prior to September 30, 2016. Program specialists, along with the program managers will submit a list of team members for each individual residing in the home to the quality assurance department. Approval will be forwarded and the program specialist will submit an ISP correction form, if necessary, to the supports coordinator. This email will be placed in the individual¿s permanent book. The program specialist will ensure that all team members, who have not decline documentation are added to all appropriate documentation, including ISP reviews. All charts will be updated prior to October 31, 2016. To ensure no further infractions occur, the program director will randomly monitor the documentation on a monthly basis. Additionally, the quality assurance department will also randomly monitor compliance on a monthly basis. |
10/31/2016
| Implemented |
6400.186(e) | Individual #1's psychologist, William Jones, was not given the option to decline. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | VCS will ensure program specialists notify the plan team members of the option to decline the ISP review documentation. The program specialist will send a declination letter to William Janes, Psychologist, in regards to Individual #1 documentation, and will forward this to the program director for verification prior to October 14, 2016. The program director, along with the quality assurance director will retrain the program specialists on 6400.186(d) prior to September 30, 2016. Program specialists, along with the program managers will submit a list of team members for each individual residing in the home to the quality assurance department. Approval will be forwarded and the program specialist will submit an ISP correction form, if necessary, to the supports coordinator. This email will be placed in the individual¿s permanent book. The program specialist will ensure that all team members receive a declination letter are sent. All charts will be updated prior to October 31, 2016. To ensure no further infractions occur, the program director will randomly monitor the documentation on a monthly basis. Additionally, the quality assurance department will also randomly monitor compliance on a monthly basis. |
10/14/2016
| Implemented |
6400.213(11) | Individual #1's current assessment states needs aid in recognizing the dangers of poisons; his current ISP states he understands precautions and would independently avoid poisonous/dangerous substances and would not ingest them. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Valley Community Services (VCS) will ensure individual record include content discrepancy in the ISP. Individual #1 understands precautions and would independently avoid poisonous/dangerous substances and would not ingest them. The program specialist will complete an addendum regarding poisons/dangerous substances and will send to all team members prior to October 14, 2016. It will be placed in the permanent chart. The program director will retrain the program specialists on 6400.213(11) prior to September 30, 2016. The program director and operations director will randomly review monthly the health and safety issues in the ISP and ensure they are accurate and followed. Additionally, the quality assurance department will randomly monitor compliance on a monthly basis. |
10/14/2016
| Implemented |