| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.181(e)(8) | Individual #1's assessment, dated 1/9/15, did not include the individual's ability to evacuate in the event of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #1's assessment, dated 1/19/15, will be updated by 9/15/15 to include the ability to evacuate in a fire. By 8/27/15, all program specialists will be trained on the requirement to include, in the assessment, the individual's ability to evacuate in a fire. Assessment documents will be audited by program management and QI staff to verify that progress on personal needs with or without assistance from others is included.
|
09/15/2015
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment, dated 1/9/15, and Individual #2's assessment, dated 4/10/15, did not include a completed lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The assessment was revised and the lifetime medical history was revised and updated to include all required areas as specified by the regulations. By 8/27/15, all program specialists will be trained on the requirement to include a completed and thorough lifetime medical history with every assessment. Assessment documents and lifetime medical histories will be audited by program management and QI staff to verify that lifetime medical histories are complete.
|
08/27/2015
| Implemented |
| 2380.181(f) | The assessment for Individual #2 was not sent to team members in the regulatory timeframe. Individual #2's assessment was completed on 4/10/15. The Individual Support Plan (ISP) meeting was held on 4/27/15. | 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). | By 8/27/15, Program Specialists will be trained on the requirement that assessments are sent to team members 30 days before the ISP meeting. Training will also involve the expectation that assessments are sent to the supports coordinator specifically not just the ISP team.
|
08/27/2015
| Implemented |
| 2380.186(a) | Individual #1's Individual Support Plan (ISP) reviews were not completed in the regulatory timeframe. The review period from October of 2014 to December of 2014 was signed on 1/30/15. The review period from January of 2015 to March of 2015 was signed on 5/4/15. Both ISP reviews exceeded the 15 day grace period. | 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 individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP. | By 8/27/15, Program Specialists will be trained on requirements for completion of Individual Support Plan (ISP) reviews on a quarterly basis. Due dates of quarterlies will be tracked by Records Coordinator who will send monthly updates to program directors so that compliance with quarterly due dates can be monitored. Directors will address non-compliance with due dates with responsible program specialists.
|
08/27/2015
| Implemented |