Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2390.22(d) | The governing body's previous meeting was held on 09/10/2015 and the most recent meeting was held on 01/26/2016. | The governing body shall meet at least quarterly. | Due to an unexpected change in the Woods Resources CEO, the December 2015 governing body meeting was not held until January 2016. Going forward, all efforts will be made to maintain quarterly meetings as required by the regulations. |
01/26/2016
| Implemented |
2390.22(e) | The governing body did not review TWE financial reports. | The governing body shall review and approve quarterly and annual financial reports. | The Executive Administrative Secretary, who takes and maintains the minutes from the governing body's meetings, was notified by the Vice President of Programs, Woods Services to include specific programs' financial report, not just general, going forward. This includes the TWE program. |
01/19/2017
| Implemented |
2390.40(b) | There was no documentation the CEO completed 24 hours of vocational or human services training within the 06/01/2015-05/31/2016 training year. | Staff in positions required by this chapter shall have at least 24 hours of training relevant to vocational or human services annually. | The CEO completed 79.00 hours of training credits during the training year June 2015 through May 2016. However, this information was not supplied to our training department to be entered onto his training record. The training department entered the information into our system and it is now reflected on his training record. (see attachment) Going forward the CEO will be reminded of the importance of handing in any training credits earned during the training year to our training department to ensure compliance with the regulations. |
05/31/2016
| Implemented |
2390.62 | There was feces and urine found in the third and fourth toilet bowl of the men's room located on the main floor. | Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. | Note: The third and fourth toilet did not contain feces. However, in one toilet there was urine and the other as a resident exited, it was noted that he did not flush his urine. During the walk thru inspection, the third and fourth toilets were flushed by Katie Wescott, Manager, TWE. The urine went down accordingly and the toilet was not clogged. Staff will continue to monitor the bathrooms for cleanliness and repair when present and report any issues to the necessary department staff. |
07/14/2016
| Implemented |
2390.124(4) | Individual # 3's record did not document an emergency medical consent form. | Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment. | Individual #3's parents were sent letters requesting they date and sign the consent for emergency medical in February 2015, a second request on March 10, 2015, and a third request on April 1, 2015 to which Woods did not receive anything back. When individual #3's mother visited on 8/12/16, she signed the consent. (see attachments)
Records Services has the following procedure:
1. Consents are mailed in January.
2. Approximately 30-45 days later, a list is compiled of those not returned to Records. A second set of consents is prepared and mailed. They are sent out under the cover of a "second request" letter.
3. Approximately 30-45 days after the second is mailed, a list is compiled of those not returned to Records and is sent out to the Program Specialists. |
08/12/2016
| Implemented |
2390.151(e)(13(ii) | Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Although the Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager to specifically address and state whether skills have been maintained, regressed or improved. (see attachment) |
09/14/2016
| Implemented |
2390.151(e)(13)(iii) | Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of 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. | Although Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager o specifically address and state whether skills have been maintained, regressed, or improved. (see attachment) |
09/14/2016
| Implemented |
2390.151(e)(13(iv) | Individual # 2's annual assessment dated 12/15/2015 did not document progress and growth in the area of 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. | Although the Vocational Program Specialists go into specific detail in regards to an individual's current functioning, they were retrained by the TWE manager to specifically address and state whether skills have been maintained, regressed or improved. (see attachment) |
09/14/2016
| Implemented |
2390.155(a) | Individual # 3¿s three month ISP review documentation dated 06/01/2015-08/31/2015 was not implemented by the ISP start dated on 06/13/2015.
Individual # 6¿s three month ISP review documentation dated 10/01/2015-12/31/2015 was not implemented by the ISP start dated on 11/01/2015.
Individual # 9¿s three month ISP review documentation dated 09/01/2015-11/30/2015 was not implemented by the ISP start dated on 11/21/2015.
Individual # 10¿s three month ISP review documentation dated 12/01/2015-02/29/2016 was not implemented by the ISP start dated on 02/23/2016.
| The ISP shall be implemented by the ISP's start date. | In order to be more efficient, Woods implemented a system on 4/1/14 whereby 3 Month reviews occur according to the calendar year as opposed to the ISP start date. Our system allows us to better track and consistently adhere to the required 3 month time frame between reviews, regardless of changing or postponed ISP dates. Although our 3 month reviews do not start on the ISP start date, there is always a review covering, documenting, and referencing an ISP start date. 155(a) states the ISP shall by implemented by the ISP's start date and that does take place in our system. Our individuals are reviewed uniformly every 3 months. On the reviews that occur during the month of the ISP start date, the ISP date and new outcomes are clearly referenced and defined in the 3 month review narrative section. To ensure that the review documents ISP implementation by the ISP start date (per reg 155), the review covering the month when the ISP takes place shows two charts: one referencing the previous outcomes and one referencing the exact ISP start date with the new outcomes created at the ISP and to be implemented on the ISP start date.
Prior to changing our system, our new procedure was reviewed with Ms. Sandra Wooters. Holly Wolbransky, Director, Woods Services, had several communications thru email and over the telephone with Ms. Wooters for approval (see attachment) While Ms. Wooters did acknowledge that we "were probably doing more than required", she did not have an issue with the new system as long as it had "date to date coverage", which Woods does. |
07/11/2016
| Implemented |
2390.156(a) | Individual # 1's three month ISP review documentation dated 07/01/2015-09/30/2015 was completed on 10/19/2015.
Individual # 1's three month ISP review documentation dated 10/01/2015-12/31/2015 was completed on 01/20/2016.
Individual # 1's three month ISP review documentation dated 01/01/2016-03/30/2016 was completed on 04/19/2016.
Individual # 2's three month ISP review documentation dated 07/01/2015-09/30/2015 was completed on 10/19/2015.
Individual # 3's three month ISP review documentation dated 03/01/2015-05/31/2015 was completed on 06/21/2015.
Individual # 3's three month ISP review documentation dated 09/01/2015-11/30/2015 was completed on 12/23/2015.
Individual # 3's three month ISP review documentation dated 12/01/2015-02/29/2016 was completed on 03/23/2016.
Individual # 4's most recent three month ISP review documentation reported on the period from 12/01/2015-02/29/2016.
Individual # 8's three month ISP review documentation dated 11/01/2015-01/31/2016 was completed on 02/17/2016.
Individual # 8's three month ISP review documentation dated 02/01/2016-04/30/2016 was completed on 05/17/2016.
| 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | TWE manager changed 3 month review due dates and retrained Vocational Program Specialists (VPS) to ensure timely collection and distribution of reviews. (see attachment)
For Individual #3, the ISP review dated 3/1/15-5/31/15 was completed on 6/11/15, not 6/21/15. The ISP review dated 9/1/15-11/30/15 was completed on 12/10/15 and not 12/23/15. These were completed within the required regulation requirement. The dates reflected were the residential assessment dates of completion and not the vocational assessments. (see attachments)
For Individual #4, it is unclear what the citation is as it seems like an incomplete statement. |
09/14/2016
| Implemented |