Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235005 Renewal 11/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, on 11/29/23, individual #2's bedroom had a very strong smell of urine.Clean and sanitary conditions shall be maintained in the home. A WorxHub request was created and maintenance was notified to find a solution to the urine odor. 01/31/2024 Implemented
6400.74At the time of the inspection on 11/29/23, the steps on the left side of the deck(if coming out of the garage door) had non-skid strips that were chipped, peeling, and missing in some spots.Interior stairs and outside steps shall have a nonskid surface. A WorxHub was created and maintenance was notified to replace the non-skid strips on the steps on the left side of the garage. 01/31/2024 Implemented
6400.112(c)The fire drill record for the 10/18/23 fire drill did not include the time it took to evacuate the home.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Program Managers have been retrained on 6400.112(c), 112(d), and 112(h) by the quality assurance director. As drills are completed, program managers are required to scan and submit the form to compliance@valleyc.org. The Quality Assurance Director or designee will review and move the form into the SharePoint. The file will be accessible to Program Managers, Program Specialists, and Operation Directors. An example of a completed Fire Drill is now placed in the binder for reference. 01/31/2024 Implemented
6400.141(c)(14)Individual #1's physical dated 9/20/23 does not address info pertinent to diagnosis in case of emergency. There is an emergency information section only on the form and this is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's annual physical form did not include information pertinent to diagnosis in an emergency. The PCP was contacted on 11.30.23 and the missing information was added to the annual physical form which was sent to the inspector on 12/1/23. Going forward, the Program Manager will ensure the information pertinent to diagnosis in an emergency is complete before leaving the PCP office. 01/31/2024 Implemented
6400.144(repeat from 1/17/23) At the time of the inspection on 11/29/23, the following medications were not available in the home for individual #1: Bisacodyl 5mgh tab PRN, Docusate sodium 100mg PRN.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Program Managers will be trained by the Quality Assurance Director on 1.22.2024. PRNs/Over-the-Counter medications, when discontinued and are not to be used again, the Program Manager is responsible for discontinuing the medications within the eMAR. Program Managers have reviewed all the listed PRNs/Over-the-Counter medications and ensured the PCP continues to want the medication available. 01/31/2024 Implemented
6400.181(d)At the time of inspection on 11/28/23, the assessment for individual #1, dated 9/2/23, had a PS signature and date however this was dated 9/2/21.The program specialist shall sign and date the assessment. The annual assessment was completed on 9/2/2023 by the Program Specialist however the date on the annual assessment was dated 9/2/2021. This was a documentation error by the Program Specialist as all other dates on the assessment paperwork were correct. Going forward, the Program Specialist will send the annual assessment to the QA Associate for review at the time of completion. The QA Associate will contact the Program Specialist with any needed corrections. This was corrected at the time of the inspection and the correction was sent to the inspector on 12.1.2023. 01/31/2024 Implemented
6400.24Staff person # 3 had a criminal record discovered upon hire, however documentation was not kept in the staff's records that the following case-by-case review was completed before hire: · The nature of the crime, · Facts surrounding the conviction, · Time elapsed since the conviction, · The evidence of the individual's rehabilitation; and · The nature and requirements of the job.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Staff #3's criminal record information did not have documentation needed in their file to show that it was okay for them to work here. A case review was completed for Staff #3 in which the nature of the crime, the facts surrounding the conviction, the time elapsed since the conviction, the evidence of the individual's rehabilitation, and the nature of the requirements of the job were reviewed and documented. It was determined Staff #3 will remain employed. 12/18/2023 Implemented
6400.46(d)Staff person # 6's date of hire was 4/1/20. There is no record that this staff person was CPR and First Aid trained before 10/18/22. Staff person # 5's date of hire was 10/22/14. There is no record that this staff person was CPR and First Aid trained before 4/27/22.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #5 and #6's CPR training needs kept in file even after it expires to show proof it was completed. 01/31/2024 Implemented
6400.165(c)(repeat from 1/17/23) Individual #1 had a PCP appointment on 4/24/23 and was diagnosed with an upper respiratory infection. The individual was prescribed Tylenol 1000mg PRN for fever, Augmentin 875mg 2x/day for 10 days and Claritin 1 tab daily for 30 days. Individual #1 received the first dose of augmentin on 4/25//23 and his last dose on 5/3/23. The individual was given this medication for a total of 9 days and not 10 days as ordered.A prescription medication shall be administered as prescribed.After review of the eMar it was discovered that the Augmentin was administered correctly but documented incorrectly on the eMar. The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for documentation will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. 01/31/2024 Implemented
6400.166(b)From January 2023 to the present, there were 42 medication administrations that were not logged immediately.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Quality Assurance has been conducting retraining at all the CLAs regarding the requirement to mark the medication administration as completed prior to the end of the allotted window. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for missing the window to document will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. 01/31/2024 Implemented
SIN-00182102 Renewal 01/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1 had a PSA completed in December 2018 and neither a manual exam nor PSA since. Provider obtained a script that the exam does not need to be completed until Individual #1 reaches 50 years of age, however, that note was obtained 1/27/21, during the Annual Inspection.The physical examination shall include: A prostate examination for men 40 years of age or older. The physical examination shall include: A prostate examination for men 40 years of age or older. Program Managers were trained on regulation 6400.141(c)(9) by the Director of Quality Assurance & Training on 03/09/21.(#9) Outline and attendance record are submitted for review. When a male individual is to turn 40, the Program Manager is responsible to contact the Primary Care Physician for clarification regarding the starting age for annual prostate checks. This information will be in written form and added to the person we serves permanent chart. Individual #1s written directions are attached for review. To ensure no further infractions occur, the Quality Assurance & Training Associate monitor during biannual inspections. 03/09/2021 Implemented
6400.145(3)The written emergency medical plan for Individuals #1, 2 and 3 did not include the emergency staffing plan in place in the event of a medical emergency.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on March 9, 2012. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individual #1, #2, and #3 form have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. 03/12/2021 Implemented
6400.181(e)(6)The 9/2/20 Assessment does not clearly define if Individual #1 has the ability to safely use or avoid poisonous materials.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. Program Specialists were trained on regulation 6400.181(e)(6) by the Director of Quality Assurance and Training 03/09/21. The outline and attendance record were submitted for review.(#11) Individual #1 Assessment has an addendum clarifying his ability to use and avoid poisonous materials. The addendum is attached for review. Program Specialists were required to review all assigned persons we serves assessment for accuracy regarding the ability to safely use or avoid poisonous materials. Addendums are to be completed and submitted to the Director of Quality Assurance & Training by 04/01/21. To ensure no further infractions occur, the Quality Assurance & Training Associate will review each Summary of Assessments ability to safely use or avoid poisonous materials for clarity and compliance, during the biannual inspections. 04/01/2021 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 1/25/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Program Managers were trained on regulation 6400.34(a) regarding the use of updated regulatory rights. The outline and attendance record is submitted for review. (#19)Individual #1 had the rights explained and signed on 08/01/20, which was within the annual year for reviewing individual rights. However, all Program Managers were responsible for reviewing updated individual rights in March 2020. The Director of Quality Assurance & Training sent an email to all Program Mangers on 02/26/2021 with the correct rights attached. Program Managers were instructed to review and complete the rights with each person and their legal guardian, as necessary, prior to the end of March 2021, making sure that they are completed on or prior to the date in 2020s individual rights. Program Specialists will review all individual rights for compliance prior to 03/31/21 and send an email to the Director of Quality Assurance & Training upon completion of the task. To ensure no further infractions occur, the Quality Assurance and Training Associate will review the Individual Rights, ensuring they were completed on the correct form and within the 365-day window, during the biannual inspections 03/31/2021 Implemented
6400.166(a)(11)Individual #1's Medication Administration Record does not list the diagnosis or purpose for the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Director of Quality Assurance & Training reviewed the MARs and requested technical support from the surveyor. With the information given, the Director of Quality Assurance & Training met with Client Services Manager at Health Direct, the pharmacy utilized by Valley Community Services, on February 24, 2021. This meeting was to ensure that the diagnosis or purpose of the medication could be added to the MARs with each individual medication. This would replace the current listing of all diagnoses on the MARs. . Program Managers Directors were trained on regulation 6400.166(a)(11) by the Director of Quality Assurance & Training on 03/09/21.Outline and attendance record are submitted for review.(#7) Program Managers will train all current medication administrators on the correct process of adding a new or time-limited medication into the MAR, which will include the diagnosis or purpose of the medication. As of April 2021, all MARs will list all the diagnosis or purpose of the medication with the medication. Program Managers will submit the completed April 2021 MAR to the Quality Assurance department prior to 05/05/21. To ensure no further infractions occur, the Quality Assurance & Training Associate will review the MARs for diagnosis or purpose of medication during biannual inspections. 03/09/2021 Implemented
SIN-00097495 Renewal 07/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
SIN-00173314 Unannounced Monitoring 06/08/2020 Compliant - Finalized
SIN-00061010 Renewal 02/06/2014 Compliant - Finalized