Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.111(c)(9) | Individual 1s physical dated 6/20/2016 was blank in the area of allergies | The physical examination shall include: Allergies or contraindicated medication. | On 12/1/16, Site Supervisor implemented a new practice and document for Program Nurse to complete a form letter requesting updated documentation following her review of individual records. On 1/4/17, Program Manager developed a new form to be updated by the Program Nurse during her monthly review. The new form documents review of each participant¿s physical. Physicals are also reviewed monthly by Program Manager to assure compliance in this area. A review of the physical document revealed that the allergy question was placed high on the second page, and is easily overlooked. Program Manager changed the spacing of the document to make all questions more visible. Program Manager also added a statement to the physical, requesting that all questions be completed. Program Manager edited the physical reminder letter to also include a request for all sections to be answered. All new practices and forms will be in use by the time of nurse review. |
01/31/2017
| Implemented |
2380.181(d) | Program Spec. did not sign the assessment dated 7/11/2016 for individual 1. | The program specialist shall sign and date the assessment. | Assessments are completed for each individual¿s semiannual review, 3 months prior to their ISP review date. A new practice was implemented in January wherein Program Manager now reviews all meeting paperwork for completion and compliance. Program Specialist is responsible for completing the assessment for inclusion with semiannual review forms. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(5) | Individual 1s ability to self-administer medications was not assessed in his assessment dated 7/11/2016. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Individual #1's Assessment was updated by Program Manager on 10/26/16. The area of self administration of medication was expanded to fully capture all skills required in self administration. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(6) | Indiividual 1s ability to safely use and avoid poisons was not assessed in his assessment dated on 7/11/2016. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Individual #1's Assessment was updated by Program Manager on 10/26/16. Questions assessing the ability to safely use and avoid poisons were added to the assessment to assure future compliance in this area. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(7) | Individual 1s knowledge of heat sources or the ability to move away quickly from heat sources was not assessed in his assessment dated 7/11/2016. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Individual #1's Assessment was updated by Program Manager on 10/26/16. Questions assessing the knowledge of, and ability to avoid, heat sources were added to the assessment to assure future compliance in this area. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(8) | Individual 1s ability to evacuate in a fire was not assessed in his assessment dated 7/11/2016. | The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire. | Individual #1's Assessment was updated by Program Manager on 10/26/16. A question assessing the individual¿s ability to evacuate in a fire was added to the assessment to assure future compliance in this area. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(10) | Individual 1s lifetime medical history was not included in the assessment dated 7/11/2016. | The assessment must include the following information: A lifetime medical history. | Individual #1's Assessment was updated by Program Manager on 10/26/16. A section for documentation of the individual¿s lifetime medical history was added to the assessment to assure future compliance in this area. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(e)(14) | Individual 1s knowledge of water safety and ability swim was not assessed in his assessment 7/1/2016. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | Individual #1's Assessment was updated by Program Manager on 10/26/16. Questions assessing the individual¿s water safety and ability to swim were added to the assessment to assure future compliance in this area. Program Specialist is responsible for completing assessments for initial reviews and yearly thereafter for semiannual reviews. Program Manager is responsible for reviewing all meeting paperwork, including assessments, for completion and compliance. Individual 1¿s semiannual review is scheduled for 1/24/17. |
01/24/2017
| Implemented |
2380.181(f) | Individual 1's assessment dated 7/11/2016 was not distributed to the SC and the team. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | A new practice was implemented in January wherein Program Manager now reviews all meeting paperwork, which includes assessments, for completion and compliance. Avenues¿ Enclosure Letter is used to document all forms sent to team members. Program Specialist is responsible for completing the enclosure letter and checking all required forms are attached for each quarterly review meeting. The inclusion of all required forms is then reviewed again and mailed by Program Manager. Individual 1¿s semiannual review is scheduled for 1/24/17. Completion of all forms for this meeting is set for 1/31/17. |
01/31/2017
| Implemented |
2380.182(a) | Individual 1 does not have an ISP. | An individual shall have one ISP. | Program Specialist is completing ISPs for all individuals who do not have support coordination services. The first version of individual 1¿s ISP will be developed at his Semiannual review meeting on 1/24/17 and completed by 1/31/17. His ISP review is in April. A new practice for individuals without Support Coordination services has been implemented. Program Specialist will be completing ISPs for individuals without Support Coordination for the individual¿s initial meeting. Program Manager is reviewing all meeting forms to assure compliance. |
01/31/2017
| Implemented |
2380.182(b)(2) | The Program Specialist is not acting as the lead for Individual 1. Individual 1 does not have a Supports Coordinator assigned to him. | When an individual is not receiving services through an SCO and does not reside in a home licensed under Chapter 6400 or 6500 (relating to community homes for individuals with mental retardation; and family living homes), the adult training facility program specialist shall be the plan lead when one of the following applies: The individual attends a facility licensed under this chapter and a facility licensed under Chapter 2390 (relating to vocational facilities). | Program Specialist is now completing the duties of plan lead. Program Specialist is completing a training review of 2380 regulations, including sections 2380.182 and 2380.186 relating to plan lead responsibilities and ISP development. Program Specialist is developing ISPs for individuals without Support Coordination services. Program Manager will review training documents and ISPs to assure compliance. |
01/24/2017
| Implemented |