| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(g) | On 1/5/17 fire drill log indicated detector in basement was not operative. New detector was not installed until 1/11/17. | If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. | Director revised the fire drill form to provide direction on this regulation on 2.5.18. All other Specialists checked for similar issues by 1.19.18. No similar issues were found. Fire Expert provided staff training on this regulation and procedure and fire training which occurred throughout the month of February. Attachment (Q) is a drill done on the new form. |
02/19/2018
| Implemented |
| 6400.113(c) | Documentation of 5/14/17 fire safety training for individual #1 and AP not in record. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | These training records were found to be missing at the time of inspection. Moving forward as of 2.1.18, fire training records for all individuals in the residential program will be copied and kept in the individual's general file with the program specialist. Fire Training sign in sheets will also be scanned and saved to the server. ID Program Director will be responsible for copying all fire training records and saving them to the server. Attachment P is the current completed training record with all individuals included. |
02/19/2018
| Implemented |
| 6400.144 | Individual #1 prescribed 40oz fluid restriction as well as less then 1500mg sodium. Neither was tracked. | 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.
| The nurse created a new tracking form for Individual #1 (attachment O - completed one) on 2.1.18. Nurses checked all other files and no similar issues were found. This new form will be used going forward for these types of items to be tracked. |
02/01/2018
| Implemented |
| 6400.181(e)(12) | Individual #1' assessment dated 8/4/17 did not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues by 2.9.18. Issues were found with 28 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)(iii) | Individual #1's assessment dated 8/4/17 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. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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 8/4/17 did not have progress and growth for 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. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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 8/4/17 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. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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 8/4/17 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. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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)(vii) | Individual #1's assessment dated 8/4/17 did not have progress and growth for financial independence. | 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.
| Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues by 2.9.18. Issues were found with 27 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)(viii) | Individual #1's assessment dated 8/4/17 did not have progress and growth for managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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)(ix) | Individual #1's assessment dated 8/4/17 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. | Attachment (N) is Individual #1 corrected assessment done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues 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 for 3/17/17, 6/19/7, 9/19/17, and 12/19/16 were 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 (K) 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(c)(1) | Individual #1's ISP review did not contain progress toward ISP outcome for monetary independence. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Note: this was an "independence" outcome:
Attachment (L) is Individual #1 corrected review done by his Program Specialist on 2.5.18. All other Specialists checked for similar issues by 2.9.18. Issues were found with 8 other updates 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 (C) is an update done post licensing/training. |
02/19/2018
| Implemented |
| 6400.186(e) | Individual #1's record did not contain option to decline for sister. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Attachment (M) 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 |