| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(6) | Individual # 1's seizure protocol in his/her current ISP is not correct. It states that Individual # 1 attends RDS day program 2x/week. The medication Ativan is not listed under his/her medications. | The program specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions under § 2380.186 for content accuracy. | Program Specialists were provided training on 4.3.18 (Attachment A). Individual #1 plan was updated on April 9th(see attachment I). Specialists found this issue in one other file and corrections were made 4.6.18. See attachment G for an ISP post licensing. |
04/13/2018
| Implemented |
| 2380.33(b)(18) | Individual # 1's PS did not have documentation that staff were trained on Individual # 1's ISP and seizure protocol. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Program Specialists were trained on 4.3.18 (see attachment A). Moving forward staff will be trained and sign off on all ISPs and Critical Revisions. Attachment J is the training sheet for the ISP and Seizure protocol. One other individual was found to have a similar issue and this was corrected 4.11.18 (K). |
04/11/2018
| Implemented |
| 2380.58(a) | Wheelchair accessible unisex Bathroom door closing mechanism/arm on top of door was not secured/attached. | Floors, walls, ceilings and other surfaces shall be in good repair. | Repair was made on 3.29.18 by the Program Manager (see attachment H). No other similar issues were found. |
03/29/2018
| Implemented |
| 2380.173(7) | A current copy of Individual # 1's ISP was not in his/her record. 12/04/17 ISP is in record. Most recent ISP updated 03/16/18 not found in record. | Each individual¿s record must include the following information: A copy of the current ISP. | Training was provided to Specialists on 4.3.18(Attachment A) and the most recent ISP for individual #1 was placed in the record, see attachment D. Moving forward, any plan update that has information in excess of what is provided in the quarterly update, the revised ISP will be printed once alerted by the SC. Attachment E is an ISP updated post licensing that was printed and place in the record. Specialists found this issue in 3 other records and updated plans were placed in file by 4.12.18. |
04/12/2018
| Implemented |
| 2380.173(9) | Individual # 2's 01/23/18 ISP states that he/she should not have access to sharp objects due to a history of self injurious behaviors. This information is not included in his/her 11/10/17 assessment. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | Program Specialists were trained on 4.3.18(attachment A). This information was added to the assessment of individual #2 on 4.6.18 by the Program Specialist, see attachment F. Both Specialists checked assessments/ISPs and one similar issues was found and corrected. Individual #1 has an ISP due on 4.26.18, attachment G is her most recent assessment and the track changes done for that ISP to show that no discrepancies exist. |
04/13/2018
| Implemented |
| 2380.183(7)(i) | Individual # 2's 01/23/18 ISP does not state his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Training was provided to Specialists on 4.3.18 (Attachment A). Individual #2 had an update due April 6th (attachment C) post licensing. This information was included in the update. Both Specialists checked and no other individuals had a similar issue. |
04/06/2018
| Implemented |
| 2380.183(7)(iii) | Individual # 2's 01/23/18 ISP does not state his/her potential to advance in competitive community integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | Training was provided to Specialists on 4.3.18 (Attachment A). Individual #2 had an update due April 6th (attachment C) post licensing. This information was included in the update. Both Specialists checked and no other individuals had a similar issue. |
04/06/2018
| Implemented |
| 2380.186(a) | Individual # 3's ISP review covering period 09/27/17-11/30/17 was not completed until 12/20/17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | Training was provided to the Specialists on 4.3.18 (attachment A). Program Specialists checked all their plans and 7 other individuals had the same issues. Both Specialists revised their schedules for review dates so they all fall within 15 days of the end of the review period. Attachment B is Individual 3¿s latest ISP review that was done within the appropriate time frame. Attachment C is an update done within timeframe post licensing. |
04/06/2018
| Implemented |