Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.31(a) | Individual #1 was not informed of individual's rights on an annual basis. Individual #1 was last informed of rights on 1-7-11. Partially implemented - adequate progress - cs - 3/5/13. | (a) Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter.
| Program Coordinators will inform their clients of their rights annually in January. Director of Residential Services will send a reminder to Coordinators and Managers in December so that individual rights are reviewed and signed off on by the required due date. Program managers will be responsible for insuring that individuals' rights are reviewed on an annual basis. Documentation of annual review of rights on 1-7-12 and 1-4-13 for Individual #1 submitted. Annual review of rights completed 1-5-12 and 1-5-13 submitted for two other individuals.
On 3-6-13 and 3-8-13 program managers and program coordinators will be retrained on requirement for annual review of individuals' rights. Training documentation will be submitted. |
01/01/2013
| Implemented |
6400.74 | RNC. On 9-27-12, the steps that exit the living area of Individual #1 onto the porch did not have a non-skid surface. Partially implemented - adequate progress - cs - 3/7/13. | Interior stairs and outside steps shall have a nonskid surface.
| Non-skid paint was applied to steps by a contractor 10/26/12. Provider submitted copy of invoice from "Handyman Klaus" for completed work. Established schedule for annual maintenance/reapplication of non-skid paint every August. Program Managers are responsible to monitor steps and stairs and other physical aspects of home on a monthly basis. Program Managers will use a Physical Site checklist (submitted) to ensure that physical site is maintained to regulatory standards. |
01/01/2013
| Implemented |
6400.181(e)(1) | Individual #1's assessment dated 9-21-12 did not include functional strengths, needs, and preferences of the individual. Partially implemented - adequate progress - cs - 3/5/13 | (e) The assessment must include the following information:
(1) Functional strengths, needs and preferences of the individual.
| The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. |
10/01/2012
| Implemented |
6400.181(e)(2) | Individual #1's assessment dated 9-21-12 did not include the likes, dislikes, and interests of the individual. Partially implemented - adequate progress - cs - 3/5/13. | (2) The likes, dislikes and interest of the individual.
| The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. |
10/01/2012
| Implemented |
6400.181(e)(11) | Individual #1's assessment dated 9-21-12 did not include a psychological evaluation. Partially implemented - adequate progress - cs - 3/5/13 | (11) Psychological evaluations, if applicable.
| The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Copies of the revised sections were submitted. Assessments, using the revised assessment tool and including psychological evaluations were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. |
10/01/2012
| Implemented |
6400.181(e)(14) | RNC. Individual #1's assessment dated 9-21-12 did not include individual's knowledge of water safety and ability to swim. Partially implemented - adequate progress - cs - 3/5/13. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim.
| The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool which includes water safety knowledge and ability to swim, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. |
10/01/2012
| Implemented |
6400.186(b) | The program specialist (Staff #1) and Individual #1 did not sign and and date the signature sheets for reviews of Individual #1's ISP completed on 1-5-12, 4-5-12, and 7-5-12. Partially implemented - adequate progress - cs - 3/5/13 | (b) The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.
| Quarterly Report Protocol dated October 1, 2012 was developed to clarify requirements of 3-month ISP reviews including signing and dating by program specialist and individual. Signed and dated ISP reviews for Individual #1 for periods 7/5/12 to 10/4/12 and 10/5/12 to 1/4/13 were submitted. Program managers and coordinators will be trained on new protocol on 3-6 and 3-8-13 and training documentation will be submitted. Per the new protocol, the Clinical Director is responsible to review and approve the completed ISP-reviews, and program managers are responsible to ensure that 3-month ISP reviews signed and dated by the individual. |
10/01/2012
| Implemented |
6400.186(e) | The program specialist (Staff #1) did not notify Individual #1's plan team members of the option to decline the documentation of ISP reviews. Partially implemented - adequate progress - cs - 3/5/13. | (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation.
| Team members have been notified and declination letters are in the casefile. Copies of declination letters sent to Individual #1's plan team members were submitted. Program managers (i.e. program specialists) will be trained on 3-6-13 and/or 3-8-13 regarding requirement to notify plan team members of option to decline ISP review documentation. Training documentation will be submitted. Residential Services Director is responsible to insure implementation of declination notices. |
12/01/2012
| Implemented |
6400.195(c) | On 9-26-12, the restrictive procedure review committee did not review Individual #1's restrictive procedure plan at least every 6 months. The last review was dated 11-8-11. Partially implemented - adequate progress - 3/6/13. | (c) The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months.
| The restrictive procedure plan was reviewed by the Human Rights Committee on 10/9/2012. The next review will be 4/9/2013. Copy of review of restrictive procedure plan on 10/9/12 submitted. Clinical Director is responsible to schedule and insure that reviews occur at least every 6 months. Residential Services Director will re-train Clinical Director on requirement during 3/13 and submit documentation of training. |
10/31/2012
| Implemented |