| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.32(b) | Staff #4 failed to provide for the general management of the facility to include implementation of policies and procedures, admission and discharge of individuals, the safety and protection of individuals and compliance with this chapter. He/she did not ensure that staff persons were trained on job duty descriptions, fire safety, and daily operations. Individuals who attend the program did not receive fire safety training or have an orientation that includes written benefits, leave policy, grievance procedures, work hours and the civil rights policy. The second floor of the facility did not have a first aid kit, the facility did not have a first aid area, exit signs did not meet minimum size requirements, emergency numbers were not posted in the building and an operable telephone was not present. Furthermore, Staff #4 failed to hold a fire drill or test fire alarms for operability in approximately a year. Fire alarms on the first floor and in the attic were not operable at the time of the inspection and the attic did not have an inspected fire extinguisher. | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: (1) Implementation of policies and procedures.
(2) Admission and discharge of individuals (3) Safety and protection of individuals. (4) Compliance with this chapter. | Chief Executive Officer personally oversaw implementation of plan of correction including review of all new forms and training processes as well as alterations to site and safety procedures. Chief Executive Officer delegated monthly monitoring systems to administrative staff who will be responsible for site and records packets, checklists, and internal audits. The CEO will participate in staff training prior to 5/1/17. |
05/01/2017
| Implemented |
| 2390.40(a) | Staff #1 and #2 were never trained in daily operations of the facility. Staff #1 started performing program specialist duties on 3/10/16 when the facility received their license to operate. Staff #1 did not receive training on his/her program specialist duties until 7/8/16. Staff #3 was hired on 9/1/16 but did not receive training in his/her program specialist duties until 9/15/16. | A facility shall provide orientation for staff relevant to their appointed positions. Staff shall be instructed in the daily operation of the facility and policies and procedures of the agency. | Staff orientation for Staff 1 documented and added to personnel file (see Appendix HH). Staff orientation for Staff 2 documented and added to personnel file (see Appendix II). All staff orientation forms added to personnel files by 5/1/17. Staff orientation forms added to all future intake packets and practices. The Program Specialist will ensure that staff orientation is complete. The Program Specialist will be trained on staff orientation prior to 5/1/17. (The administrative assistant will review on a monthly basis the records regarding 40(a) to measure compliance and sign off on a spread sheet.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.58 | The vocational facility building did not have an operable, noncoin operated telephone. | A facility shall have an operable, noncoin operated telephone. | Telephone with number (717)440-5556 added to prevocational site (see Appendix GG). The Program Specialist will review with staff the phone location and location emergency numbers prior to 5/1/17.( The agency will have a landline installed by 6/1/17. The administrative assistance will review the site location checklist completed by the P.S on a monthly basis and sign off on appropriate documentation.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.60(b) | The facility did not have a first aid area, nor did they have a bed, cot, or a blanket. | The first aid area shall have a bed or cot, a blanket and a first aid kit. | Kitchen on second floor designated as first aid area. First aid area supplied with inflatable mattress, blankets, and stocked first aid kit (see Appendix FF). The Program Specialist will ensure that the first aid area is complete. The Program Specialist will check the first aid area monthly and utilize the monthly safety checklist. The Program Specialist will be trained on the monthly safety checklist prior to 5/1/17.(The administrative assistant will review the monthly checklists completed by the P.S on a monthly basis and sign off on approved spread sheet.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.60(c) | The second floor of the facility did not have a first aid kit. | Each floor of the facility shall have a first aid kit accessible to staff. | Second floor supplied with first aid kit found in closet of second floor kitchen (see Appendix FF). The Program Specialist will ensure that the first aid kits complete prior to 4/15/17. The Program Specialist will check the first aid kits monthly. The Program Specialist will check the first aid kits monthly and utilize the monthly safety checklist. The Program Specialist will be trained on the monthly safety checklist prior to 5/1/17. ( The administrative assistant will review the safety checklist monthly and sign off on the appropriate form.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.65 | The interior stairs leading to the second floor were not equiped with nonskid surfaces. There was approximately 20 steps. | Interior stairs shall have a nonskid surface. | Interior stairs painted with gradient paint to apply nonskid surface (see Appendices MM and NN). The Program Specialist will check the stairs monthly and will utilize the monthly safety checklist. The program specialist will be trained on the monthly safety checklist prior to 5/1/17. (The administrative assistance will review the safety checklist on a monthly basis and sign off on the appropriate form.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.74(d) | The bathroom off of the kitchen did not have individual clean paper or cloth towels or a hand dryer. | Each lavatory shall have a sink, wall mirror, soap, toilet paper and individual clean paper or cloth towels or air hand dryer. | Paper towels replaced in second floor bathroom and hand towels placed on mounted hooks (see Appendix EE). Bathrooms added to monthly site inspection chart (see Appendix CC). The Program Specialist will ensure that this is checked monthly. The Program Specialist will be trained on the monthly safety checklist prior to 5/1/17. ( The administrative assistant will review the inspection chart monthly and sign off on the appropriate form). JR 5/2/17 |
05/01/2017
| Implemented |
| 2390.82(a) | The written emergency evacuation procedure did not include a means of transportation. | Written emergency evacuation procedures including at a minimum client and staff responsibilities, means of transportation in an emergency, emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in work areas. | Evacuation procedures amended to include a means of transportation (see Appendix DD). Staff will be trained prior to 5/1/17.(The administrative assistant will review the record on a quarterly basis to make sure that the plan is still up to date and sign off on appropriate form when this review is completed.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.83(a) | The fire alarms in the attic and on the first floor were not operable. The did not contain batteries. The fire alarm on the second floor was not loud enough to be audible throughout the facility. | There shall be an operable fire alarm that is audible throughout the facility. | Fire alarms tested and batteries replaced¿found to be audible throughout facility once functioning. Fire alarms added to monthly site inspection chart (see Appendix CC). The Program Specialist will ensure fire alarms are tested monthly and functioning. If one is not, staff will follow the protocol in the policy manual to have it repaired. Staff will be trained prior to 5/1/17. ( The administrative assistant will review form documenting fire alarm tests and functioning on a monthly basis and sign off that this reviewed on appropriate form.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.83(b)-1 | Since the facility opened on 3/10/16, there has not been any monthly fire alarm equipment checks conducted on the alarms located at the facility. | An employe trained in the operation of the equipment shall check the fire alarm monthly. | Fire alarm equipment checked and found to be functional. Audible fire alarm installed in second floor (see Appendix LL). Fire alarms added to monthly site inspection chart (see Appendix CC). The Program Specialist will ensure fire alarms are tested monthly and functioning. If one is not, staff will follow the protocol in the policy manual to have it repaired. Staff will be trained prior to 5/1/17. ( The administrative assistant will review the site inspection chart monthly and sign off that it has been completed on appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.84(a) | The attic did not contain a fire extinquisher that was inspected. | There shall be at least one fire extinguisher with a minimum 10ABC rating for each floor including the basement. If there is more than 1,500 square feet of indoor floor area on any floor including the basement, there shall be an additional fire extinguisher with a minimum 10ABC rating for each additional 1,500 square feet of indoor floor area. | Fire extinguisher added and certified by KINT Fire Protection on 3/15/17 (see Appendix AA). The Program Specialist will ensure that fire extinguishers are present and current and will use the monthly safety checklist. The Program Specialist will be trained on the monthly safety checklist prior to 5/1/17. The administrative assistant will review the safety checklist monthly and sign off that it was completed on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.84(d) | All fire extinguishers in the program were under 45 pounds and none were mounted to the wall. | Fire extinguishers weighing under 45 pounds shall be mounted on the wall so that the extinguishers are visible to staff and clients. | All fire extinguishers mounted to walls in their appropriate locations (see Appendix BB). The Program Specialist will ensure that fire extinguishers are present and current. The Program Specialist will utilize the monthly safety checklist. The Program Specialist will be trained on the monthly safety checklist prior to 5/1/17. ( The administrative assistant will review the safety checklist and sign off to verify that it was completed on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.85(a)-1 | The facilty was licensed for operation on 3/10/16 and a fire drill has not been conducted at the facility since then. There have been individuals participating in the program since 3/10/16. Staff #4 indicated that all fire drill have been conducted at another building, not licensed under the 2390 program. | A fire drill shall be held at least every 90 calendar days. | Fire drill conducted and documented by staff at prevocational site on 3/29/2017 (see Appendix Z). All fire drills will be conducted by prevocational staff at prevocational site on quarterly (90 day) basis. The Program Specialist will ensure that fire drills are conducted and will check the fire drill log quarterly.(The administrative assistant will review the fire drill logs quarterly and sign off on the appropriate form to show compliance. Staff in the facility shall be trained in this regulation by 5/17/17.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.86-3 | All exit signs, approximately 5 in total, were only 3 inches high and 1/4th inch wide. | Exit sign letters shall be at least 6 inches in height with the principal strokes of letters not less than 3/4 inch wide. | Exit signs with letters 6¿¿ tall and 0.75¿¿ printed (see Appendix Y) and added to necessary locations at prevocational site (see Appendix KK). The Program Specialist will check the signs monthly. Checking the signs are added to the monthly site safety checklist. The Program Specialist will be trained on the monthly site checklist prior to 5/1/17. (The administrative assistant will review the safety checklist monthly and sign off this has been completed on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.87 | All staff and individuals attending the program never received fire safety training for the vocational facility. Staff #4 indicated that staff and individuals are instructed on fire safety for the day program building, not attached to the vocational workshop. | Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept. | Initial Fire Safety Training for all current participants conducted by 3/31/17 (see Appendix JJ). Fire Safety Training added to all intake packets and processes as well as internal auditing instrument (see Appendix A). Initial Tests taken by all staffs inserted into Fire & Emergency record (see Appendices U, V, and W). Fire Safety tests added to staff intake packets and processes. The Program Specialist will ensure that fire safety training is conducted and documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all staff records quarterly to and sign off on appropriate form to show compliance.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.103 | The facility did not have a written emergency medical plan. | A facility shall have a written emergency medical plan listing the following:(1)The hospital or source of health care that will be used in an emergency. (2) The method of transportation to be used.(3) Written consent from the client, parent or guardian for emergency medical treatment.(4) The staffing plan during the emergency. | Emergency medical plan composed and added to Prevocational Fire & Emergency procedures folder (see Appendix T). Emergency medical plan likewise amended to Prevocational Policy Manual (Appendix II). The Program Specialist will train all staff on the plans prior to 5/1/17. ( The administrative assistant will review the facility emergency medical plan quarterly and sign off this has been completed on appropriate form.)JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.111(a) | Individuals #1 and #2 did not have a preadmission interview. | A client shall have a preadmission interview. | Individual 1¿s preadmission interview documented, signed, and added to client file (see Appendix R). Individual 2¿s preadmission interview documented, signed, and added to client file (see Appendix S). Preadmission interview added to internal auditing instrument (see Appendix A) and to client intake packet. Preadmission interviews added to all future intake packets and processes. The Program Specialist will ensure that preadmission interviews occur and are documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records on a quarterly basis and sign off on appropriate form to show compliance with the regulation.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.111(b)-1 | Individuals #1 and #2 were not notified in writing if they were accepted for services. | Within 30 calendar days following the interview, the client shall be notified in writing if he has been accepted for services. | Written notification of acceptance for services signed by Individual 1 and added to client file (see Appendix P). Written notification of acceptance for services signed by individual 2 and added to client file (see Appendix Q). Written notification of acceptance for services signed by all active participants by 6/1/17 and acceptance letters added to all intake packets and processes. The Program Specialist will ensure that acceptance of services are obtained and documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 111(b)1 and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.112(a)-1 | Individuals #1 and #2 were not oriented to the facility and to the services offered. | Upon admission, a client shall be oriented to the facility and to the services offered. | Orientation conducted at admission for each client but not noted. Individual 1¿s orientation form signed and added to client file (see Appendix N). Individual 2¿s orientation form signed and added to client file (see Appendix O). All other active participants¿ will complete orientation process and form by 5/1/17 and orientation form will utilized in future intake packets and process. The Program Specialist will ensure that all participants receive orientation and that it will be documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 112(a)1 and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.112(b)-1 | Individuals #1 and #2 did not receive written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. | Upon admission, a client shall be given written information outlining working hours, benefits, leave policy, civil rights policies and procedures and grievance procedures. This information shall be explained to the client. | Individual 1 (see Appendix P) Working hours, benefits, leave policy, civil rights policies, and grievance procedures covered in admission letters for Individual 2 (see Appendix Q). Admission letters will be issued and signed by all active participants by 5/1/17 and admission letters will be used in all future intake packets and processes. The Program Specialist will ensure that written letters are signed and documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 112(b)1 and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.124(1) | Individuals #1 and #2's record did not include their place of birth. | Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge. | Individual 1¿s Participant Information Sheet amended to include place of birth and added to Client File (see Appendix G). Individual 2¿s Participant Information Sheet amended to include place of birth and added to client file (see Appendix H). All active participants¿ Participant Information Sheets have been revised, and revised Participant Information Sheet will be used in future participant intake packets and process. The Program Specialist will ensure that each client record includes this information. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 124(1) and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.124(2) | Individuals #1 and #2's record did not include the name, address, and telephone number of a designated person to be contacted in case of an emergency. | Each client's record must include the following information: The name, address and telephone number of parents, legal guardian and a designated person to be contacted in case of an emergency. | Individual 1¿s Participant Contact Form amended to specify emergency contact (see Appendix I). Individual 2¿s Participant Contact Form amended to specify emergency contact (see Appendix J).All active participants¿ Participant Contact Form amended to signify emergency contact and revised Participant Contact Form will be used in future participant intake packets and process. The Program Specialist will ensure that each client record includes this information. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 124(2) and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.124(8)(i) | Individual #1's record did not include a copy of the invitation to their initial Individual Support Plan (ISP) meeting. Individual #1's date of admission to the facility was 10/6/16 and their annual ISP was updated by 1/30/17. The ISP meeting was held after his/her date of admission. | Each client's record must include the following information: A copy of the invitation to: The initial ISP meeting. | Individual 1¿s invitation to their ISP meeting added to client file (see Appendix K). Invitations for ISP meetings and ISP reviews added to internal auditing instrument (see Appendix A). The Program Specialist will ensure that invitations are sent and documented in the client file. The Program Specialist will be trained on the auditing instrument prior to 5/1/17. (The administrative assistant will review all individual records quarterly in regards to 124(8)(I) and sign off on the appropriate form.) JR 5/2/17. |
05/01/2017
| Implemented |
| 2390.124(9)(i) | Individual #1's record did not include a copy of the Individual Support Plan (ISP) meeting signature sheet. Individual #1's date of admission to the facility was 10/6/16 and their annual ISP was updated by 1/30/17. The ISP meeting was held after his/her date of admission. | Each client's record must include the following information: A copy of the signature sheet for: The initial ISP meeting. | Individual 1¿s ISP signature sheet for meeting dated 1/30/2017 added to client file (see Appendix L). ISP Signature sheets added to internal auditing instrument.(The program specialist will review monthly any meetings for the individuals and sign off that this has been completed. The administrative assistant will review all individual ISP signature pages monthly and sign off to on the appropriate form. Staff will be training on the regulation and how to properly implement moving forward by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.124(10) | The Individual Support Plan (ISP) in Individual #1's record was last updated on 9/8/16, prior to his/her date of admission on 10/6/16. His/Her most recently updated and available ISP was last updated on 1/30/17. This recently updated ISP was not in his/her record. | Each client's record must include the following information: A copy of the current ISP. | ISP update dated 1/30/2017 added to client file (see Appendix M). ISP Reviews added to internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 124(10)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.151(a) | Individual #1 did not have an assessment created for him/her for the vocational facility. Staff #3 indicated that the assesment for Individual #1 was created for his/her day program needs. | Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual 1¿s prevocational assessment dated 12/6/2016 added to client file (see Appendix D). Prevocational assessment including reviews added to internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 151(a)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.151(e)(1) | Indvidiual #2's 5/2/16 assessment did not include functional strengths, needs and preferences regarding the vocational workshop. | The assessment must include the following information: Functional strengths, needs and preferences of the client. | Individual 2¿s Prevocational Assessment including functional strengths, needs, and preferences dated 11/18/16 added to client file (see Appendix E); auditor incorrectly cited date of 2380 assessment. Prevocational Assessment added to internal auditing instrument (see Appendix A) and 2390 filing system implemented. ( The P.S will review all client files to make sure 151(e)(1)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.151(e)(9) | Indvidiual #2's 5/2/16 assessment did not include documentation of their disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the client's disability, including functional and medical limitations. | Individual 2¿s Prevocational Assessment including documentation of disability, including functional and medical limitations, dated 11/18/16 added to client file (see Appendix E); auditor incorrectly cited date of 2380 assessment. Prevocational Assessment added to internal auditing instrument (see Appendix A) and 2390 filing system implemented. ( The P.S will review all client files to make sure 151(e)(9)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.151(e)(10) | Indvidiual #2's 5/2/16 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual 2¿s medical history added to client file (see Appendix F) and internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 151(e)(10) is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.151(e)(12) | Indvidiual #2's 5/2/16 assessment did not include recommendations for specific areas ofvocational training or placement and competitive community-integrated employment. | The assessment must include the following information: Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | Individual 2¿s Prevocational Assessment including vocational recommendations dated 11/18/16 added to client file (see Appendix E); auditor incorrectly cited date of 2380 assessment. Prevocational Assessment added to internal auditing instrument (see Appendix A) and 2390 filing system implemented. ( The P.S will review all client files to make sure 151(e)(12)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.153(4) | Indvidiual #2's Individual Support Plan (ISP) did not include his/her supervision levels for the vocational workplace. Individual #1's ISP indicated that he/she did not need direct supervision at all times. His/Her ISP did not indicate a specific period of time he/she could be unsupervised or a plan to increase his/her level of unsupervised needs. | The ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the client to be without direct supervision, if the client's current assessment states the client may be without direct supervision and if the client's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve a higher level of independence. | Individual 2¿s ISP review dated 11/17/2016 contains Supervision Care Needs under Health and Safety section (see Appendix B). Individual¿s 2¿s prevocational assessment dated 11/18/2016 likewise contains supervision guidelines (see Appendix E). ( The P.S will review all client files to make sure 153(4)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.153(5) | Individual #1's Indviidual Support Plan (ISP) did not include a protocol to address his/her social, emotional, and environmental needs. He/She was diagnosed with Bipolar disorder and Obsessive Compulsive disorder for which he/she was prescribed Risperdal and Geodon respectively. | A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | SEEN Plan Request sent to Individual 1¿s Supports Coordinator on 3/30/2017 (see Appendix C) and will be added to Individual 2¿s file upon receipt. SEEN Plan Request and Seen Plan added to internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 153(5)is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.154(a)(1)(iii) | A direct services worker did not participate in Individual #2's Individual Support Plan meeting. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2390.156 (relating to ISP review and revision). A plan team must include as its members the following: A direct service worker who works with the client from each provider delivering a service to the client. | Letter explaining absence of direct care staff and direct care¿s staff review of ISP added to Individual 2¿s file (see Appendix KK).(Staff will be trained on this regulation by 5/17/17. The P.S will make sure a direct service worker is attendance moving forward. The administrative assistant will review on a monthly basis and sign off on appropriate form. ) JR 5/2/17. |
04/12/2017
| Implemented |
| 2390.156(a) | Individual #1's date of admission to the facility was 10/6/16 and he/she did not have an Individual Support Plan (ISP) review completed yet at the time of licensing on 2/16/17. He/She required an ISP review to be completed by 1/6/17. | 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. | DH first enrolled in 2390 on 1/25/17, meaning ISP review would not be required until 4/25/17. Auditor incorrectly cited 2380 enrollment date of 10/6/16. Separate filing system for 2390 program instituted with ISP reviews required by internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 156(a) is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/01/2017
| Implemented |
| 2390.156(b) | Individual #2 did not sign and date his/her Individual Support Plan (ISP) review created on 11/14/16. | The program specialist and client shall sign and date the ISP review signature sheet upon review of the ISP. | Supports Coordinator and Program Specialist could not identify ISP review dated 11/14/16. ISP Review signature sheet nonetheless added to internal auditing instrument (see Appendix A). ( The P.S will review all client files to make sure 156(b) is being implemented. The administrative assistant will then review all client files and sign off on appropriate form that this regulation is being implemented. Staff will be trained on the regulation by 5/17/17.)JR 5/2/17. |
04/12/2017
| Implemented |