| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The bathroom mirror was broken. The bottom part of the mirror was a mirrored, medication cabinet and it was rusted. The right side mirror didn¿t have a handle or slide properly without falling. | Floors, walls, ceilings and other surfaces shall be in good repair. | The mirror unit was replace by maintenance on October 26th as seen in attachment C6. All other homes were checked by the site supervisors the week of 10.26.15 and no similar issues were found. |
10/30/2015
| Implemented |
| 6400.163(c) | The medication reviews for Individual #1 stated that they were prescribed Risperdal for a diagnosis of Intellectual Disabilities. Their Indivdual Support Plan stated that they were prescribed Risperdal for Impulse Control Disorder. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The medication reveiw for individual #1 was amended by the Medical Specialist on 10.21.15 as seen in attachment C4. No other indivdiuals were found to have similar issues. A training covering this information was provided to programming staff on October 22nd. as seen in attachment C5. |
10/22/2015
| Implemented |
| 6400.168(a) | Staff #1 did not complete their annual medication practicum in it's entirety for 2014. The only completed 2 observations for the year. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | A Med Admin Trainer completed training with Staff #1 on 10.18.15 as seen in attachment B1. Other staff were also found to have this issue and completed training as of 11.3.15 as seen in training records which are attachment B2. Med Trainers reviewed all MARS on a daily basis for all untrained staff until training completion as seen in attachment B3. To correct this issue in the future, the medical team will reveiw 25% of each trainer's staff each quarter to ensure MARS are being done correctly and documentation is in place. Also the Med Trainers have established a relationship with the ODP Med Training consultant so they can ask questions or get feedback on processes at any time. |
11/03/2015
| Implemented |
| 6400.168(d) | Staff #1 did not complete their annual medication practicum in it's entirety for 2014. The only completed 2 observations for the year. Staff #1 has medications for the past year on a regular basis. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | A Med Admin Trainer completed training with Staff #1 on 10.18.15 as seen in attachment B1. Other staff were also found to have this issue and completed training as of 11.3.15 as seen in training records which are attachment B2. Med Trainers reviewed all MARS on a daily basis for all untrained staff until training completion as seen in attachment B3. To correct this issue in the future, the medical team will reveiw 25% of each trainer's staff each quarter to ensure MARS are being done correctly and documentation is in place. Also the Med Trainers have established a relationship with the ODP Med Training consultant so they can ask questions or get feedback on processes at any time. |
11/03/2015
| Implemented |
| 6400.181(e)(4) | The assessment for Individual #1 did not include their need for supervision within the community. The assessment stated that Individual #1 could be unsupervised in the community for 8 hours but it didn¿t specify whether that was per day, per week, or per month. | The assessment must include the following information: The individual's need for supervision.
| The assessment was ammended by the Program Specialist on 11.2.15 to include this information as seen in attachment C7, all other plans were checked and none had similar issues. A training regarding this issue was completed on 10.22.15 as seen in attachment C5 to prevent this issue from reoccurring. |
11/02/2015
| Implemented |
| 6400.181(f) | The assessment for Individual #1 wasn't sent to behavior support or his skills vocational program. Behavior support started 5/16/15 and he was attending skills program at this time. The assessment was sent 6/5/15. | (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).
| The assessment for individual #1 was sent to behavior support and SKills by the Program Specialist on 11.2.15 as evidenced by attachment C10. To prevent this oversight in the future additional lines were added to the cover letter to include behavior support and any additional services. Training was provided on 10.22.15 as evidenced by attachment C5. |
11/02/2015
| Implemented |
| 6400.185(b) | The Individual Support Plan (ISP) for Individual #1 stated he could handle up to $20 independently. On 7/14/15 Individual #1 was given $29 to handle independently. | The ISP shall be implemented as written. | Individual #1's October log for November is attachment C1 and staff were trained on his plan by the Site Supervisor on 10.30.15as seen in attachment C2. The rep-payee did not find any other similar issues. Moving forward, all logs will have space to input the amount of cash an individual can carry. This will serve as a quick reference for staff and will also allow the rep-payee to check this information when the logs come in for the month. This form can also be seen in CI. The spreadsheet has a special feature that will send an automatic alert if the money given to the individual exceeds the amount the plan outlines. |
10/30/2015
| Implemented |
| 6400.186(d) | The Individual Support Plan (ISP) review dated 4/16/15 was not sent to his Skills vocational program he was attending at the time. | 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. | The Plan for individual #1 was sent to SKills by the Program Specialist on 11.2.15 as evidenced by attachment C8. No other indivdiuals were found to have similar issues. To prevent this oversight in the future the cover sheet was updated to include additional lines for all team members and training was provided on 10.22.15 as evidenced by attachment C5. |
11/02/2015
| Implemented |
| 6400.186(e) | Individual #1's supports coodinater, atf program, and behavior support team members were not notified of their option to decline the Individual Support Plan (ISP) review information. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The delination documentation was found and is attachemtnd C9 but not all team members were on it so this issue still existed. Individual #1's missing team member was contacted by the Program Specialist on 11.2.15 and notiifed of their option to decline as evidenced in attachment C9. No similar issues existed. Training was provided to staff on 10.22.15 as evidenced by attachment C5. |
11/02/2015
| Implemented |