Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.91(a) | Both Individual #1 and Individual #2 had late annual fire training. Training was held on 04-19-18 and then not again until 05-18-19. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | The annual training was completed a month late. In order to ensure that this is completed annually per regulation, the responsibility has been assigned to the chair of the safety committee, Currently Nathan Rice, Internal Operations Manager. The fire safety training has been scheduled to occur on Friday, October 18, 2019. It has been rescheduled to coincide with National Fire Prevention month which occurs every October. If any staff or individuals are not in attendance on this day, the training will be completed for them by the end of October. |
10/10/2019
| Implemented |
2380.181(e)(13)(i) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of health | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress over the past year and current level of functioning in the area of Health.
Current completed assessments will have this progress and from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year.
the Program Specialist will be responsible for ensuring this occurs. |
11/30/2019
| Implemented |
2380.181(e)(13)(ii) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of motor and communication skills. | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress and growth over the past year in the area of motor and communication skills.
Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year.
the Program Specialist will be responsible for ensuring this occurs. |
11/30/2019
| Implemented |
2380.181(e)(13)(iii) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of personal adjustment. | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress and growth over the past year in the area of Personal Adjustment.
Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year.
the Program Specialist will be responsible for ensuring this occurs. |
11/30/2019
| Implemented |
2380.181(e)(13)(iv) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of socialization | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress and growth over the past year in the area of Socialization.
Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year.
the Program Specialist will be responsible for ensuring this occurs. |
11/30/2019
| Implemented |
2380.181(e)(13)(v) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of recreation. | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress and growth over the past year in the area of Recreation.
Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year.
the Program Specialist will be responsible for ensuring this occurs. |
11/30/2019
| Implemented |
2380.181(e)(13)(vi) | Progress and growth over the last year is not addressed anywhere in either Individual #1's or Individual #2's assessments in the area of community integration. | 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. | The Serve, Inc. Initial/annual assessment has been updated to correlate with the regulations. The assessment was updated to follow the guidelines for the development, annual update and revision of the individual plan.
All assessments will include progress and growth over the past year in the area of community integration.
Current completed assessments will have this progress and growth from the prior year added to their current assessment by the Program Specialist - Elizabeth Cole by November 30, 2019.
All newly completed assessments will cover the progress and growth from the prior year. |
11/30/2019
| Implemented |
2380.36(b) | Staff #1 and #2 had late annual fire safety training. Training was held on 04-19-18 and then not again until 05-18-19. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The annual training was completed a month late. In order to ensure that this is completed annually per regulation, the responsibility has been assigned to the chair of the safety committee, Currently Nathan Rice, Internal Operations Manager. The fire safety training has been scheduled to occur on Friday, October 18, 2019. It has been rescheduled to coincide with National Fire Prevention month which occurs every October. If any staff or individuals are not in attendance on this day, the training will be completed for them by the end of October. |
10/10/2019
| Implemented |