Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.181(e)(13)(iii) | Individual #1's assessment dated 6/24/17 did not have progress and growth for residential living. | 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. | This section of the Assessment was updated (I) for BM on 1.30.18 by her Program Specialist. All other assessments were checked by the Program Specialists by 2.9.18. Issues were found with 12 other assessments and corrections were made by 2.19.18 A training was provided to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (J) is an assessment done post licensing/training. |
02/19/2018
| Implemented |
6400.181(e)(13)(iv) | Individual #1's assessment dated 6/24/17 did not have progress and growth in 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. | This section of the Assessment was updated (I) for BM on 1.30.18 by her Program Specialist. All other assessments were checked by the Program Specialists by 2.9.18. Issues were found with 14 other assessments and corrections were made by 2.19.18 A training was provided to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (J) is an assessment done post licensing/training. |
02/19/2018
| Implemented |
6400.181(e)(13)(v) | Individual #1's assessment dated 6/24/17 did not have progress and growth for 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. | This section of the Assessment was updated (I) for BM on 1.30.18 by her Program Specialist. All other assessments were checked by the Program Specialists by 2.9.18. Issues were found with 26 other assessments and corrections were made by 2.19.18 A training was provided to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (J) is an assessment done post licensing/training. |
02/19/2018
| Implemented |
6400.181(e)(13)(vi) | Individual #1's assessment dated 6/24/17 did not have progress and growth for 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. | This section of the Assessment was updated (I) for Individual #1 on 1.30.18 by her Program Specialist. All other assessments were checked by the Program Specialists by 2.9.18. Issues were found with 10 other assessments and corrections were made by 2.19.18 A training was provided to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (J) is an assessment done post licensing/training. |
02/19/2018
| Implemented |
6400.181(e)(13)(ix) | Individual #1's assessment dated 6/24/17 did not have progress and growth for 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. | This section of the Assessment was updated (I) for Individual #1 on 1.30.18 by her Program Specialist. All other assessments were checked by the Program Specialists by 2.9.18. Issues were found with 10 other assessments and corrections were made by 2.19.18 A training was provided to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (J) is an assessment done post licensing/training. |
02/19/2018
| Implemented |
6400.186(a) | Individual #1's ISP reviews dated 11/14/17, 7/25/17, 4/25/17, and 1/25/17 were completed late. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Attachment (A) is a list of Individual #1's revised quarterly schedule done by her Program Specialist. All other Specialists checked for similar issues by 2.5.18. Issues were found with 18 other schedules and corrections were made by 2.9.18 A training was provided by the Executive Director to Program Specialists at the QARM meeting on 1.25.18 (B). Attachment (C) is a quarterly done post licensing/training showing it was completed within the correct timeframes. |
02/09/2018
| Implemented |
6400.186(d) | Individual #1's ISP reviews dated 11/14/17, 7/25/17, and 4/25/17 were not sent to all team members. | 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. | Program Specialist resent Individual #1 ISP to all parties who were missed on 1.26.18(D). All other Specialists checked for similar issues by 2.5.18. Issues were found with 14 other ISPs and corrections were made by 2.9.18. A training was provided to Program Specialists by the Executive Director at the QARM meeting on 1.25.18 (B). Attachment (E) is a distribution letter done post licensing/training. |
02/09/2018
| Implemented |
6400.186(e) | Individual #1's record did not contain an option to decline. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Attachment (F) is Individual #1 corrected declination done by the Program Specialist. All other Specialists checked for similar issues by 2.5.18. Issues were found with 9 other declinations and corrections were made by 2.9.18. Attachment( G) is the procedure and documents developed by the Director that will be used going forward to complete the declination process. Attachment (H) is an example of one done on with the new process post licensing. |
02/09/2018
| Implemented |