| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.35(d) | The agency did not have documentation that floor supervisor, Staff #1, possessed 30 credit hours from an accredited college or university, a high school diploma, or a general education development certificate. | A floor supervisor shall meet one of the following qualifications: (1) Possess 30 credit hours from an accredited college or university.(2) Possess a high school diploma or a general education development certificate, and 1 year work experience in industry or rehabilitation. | A floor supervisor shall meet one of the following qualifications: (1) Possess 30 credit hours from an accredited college or university. (2) Possess a high school diploma or a general education development (GED) certificate, and 1 year work experience in industry or rehabilitation.
The CEO and/or Director is responsible to ensure compliance with regulation 2390.35(d), including maintaining a copy of documentation from accredited college or university or high school diploma or GED certificate within staff¿s personnel file.
A copy of Staff #1¿s High School Equivalency Credential was issued on 12/30/2009 from The Commonwealth of Massachusetts Board of Education. (Attachment #25 ¿ GED Certificate) |
08/23/2018
| Implemented |
| 2390.51 | Individual #3 is deaf and can not hear the strobes lights attached to the fire alarm throughout the facility. The first aid room was not equipped with a strobe light. The strobe light in the main workshop area was barely visible throughout the workshop. | For facilities serving physically handicapped clients, accommodations such as ramping and wide doorways shall be made to ensure the maximum physical accessibility feasible for entrance to, movement within, and exit from the facility, based upon each client's physical characteristics. | The CEO and Director are responsibility to ensure compliance with regulation 2390.51, which states that facilities serving physically handicapped clients, accommodations such as ramping and wide doorways shall be made to ensure the maximum physical accessibility feasible for entrance to, movement within, and exit from the facility, based upon each client¿s physical characteristics.
The first aid room was moved onto the work floor, therefore an additional strobe will not be added to that space since it is being used for storage. On 09/13/2018, Commonwealth Security swapped out a Horn Wheelock for a Horn/Strobe Wheelock combination, thus the work floor now has 2 strobes. Per Commonwealth Security personnel, the ¿dim¿ strobe light on the work floor is operating sufficiently, therefore the strobe light itself did not need to be replaced, however the batteries were replaced. (Attachment #24- Invoice) |
09/13/2018
| Implemented |
| 2390.87 | The written record of Individuals #1's and #2's fire safety training did not indicate that training in the use of fire extinguishers occurred. | 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. | Vocational Program Specialists are responsible to ensure compliance with regulation 2390.87, which states: 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.
The Vocational Program Specialists were trained in the requirements of regulation 2390.87. (Attachment #21- Training sheet & Attachment #22- Memo)
The Client¿s Annual Fire Safety form was revised on 08/16/2018 to include the verbiage ¿Use of Fire Extinguisher¿ Video. (Attachment #23 ¿ Annual Fire Safety Training form)
The Client¿s Annual Fire Safety training is held each year in October. The new form will be used at that time.
Vocational Program Specialists will ensure their caseloads are in compliance with this regulation. All records will be in compliance with this regulation by 10/31/2018. |
10/31/2018
| Implemented |
| 2390.151(a) | Individual #1's assessment was completed on 5/17/17 and not again until 6/6/18, outside the annual time frame. | 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. | The Vocational Program Specialist is responsible to ensure each client has an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(a). (Attachment #16-Training sheet & Attachment #17 -Memo)
An individual #1's assessment was completed timely. (Attachment # 18 ¿ Assessment 2017 - Letter, 1st and Last page & Attachment #19 ¿ Assessment 2018 - Letter, 1st and Last page)
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/15/2018. |
10/15/2018
| Implemented |
| 2390.151(e)(4) | Individual #2's 9/15/17 assessment did not include his/her amount of unsupervised time appropriate for the workshop setting or the level of supervision needed in the community with the day program staff. | The assessment must include the following information: The client's need for supervision. | The Vocational Program Specialist is responsible to ensure the assessment includes the following information - the client¿s need for supervision.
The Vocational Program Specialists were trained in the requirements of regulation 2390.151(e)(4). (Attachment #16- Training sheet & Attachment #17- Memo)
Individual #2 ¿ An Assessment Addendum was completed (09/12/2018) to include the amount of unsupervised time appropriate for the workshop setting and the level of supervision needed in the community with the day program staff. (Attachment #20- Assessment Addendum)
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/16/2018. |
11/16/2018
| Implemented |
| 2390.153(4) | Individual #2's Individual Support Plan (ISP) did not include the level of supervision needed in the community with vocational staff or the amount of unsupervised time Individual #2 is assessed to have at the workshop facility. | 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. | The Vocational Program Specialist is responsible to ensure that the ISP, including annual updates and revisions under § 2390.156 (relating to ISP review and revision) includes the following: (4) 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.
The Vocational Program Specialists were trained in the requirements of regulation 2390.153(4). (Attachment #13-Training sheet & Attachment #14 -Memo)
Individual #2 - An e-mail was sent to Supports Coordinator on 09/11/2018 requesting the Supervision Care Needs section of the ISP be revised to include his current level of supervision needed in the community with vocational staff and the amount of unsupervised time Individual #2 is assessed to have at the workshop facility. (Attachment #15 ¿E-mail)
Vocational Program Specialists are in the process of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 11/16/2018. |
11/16/2018
| Implemented |
| 2390.156(c)(2) | Individuals #1's and #2's Individual Support Plan (ISP) reviews did not contain a review of their community participation. Individual #1's ISP reviews were completed on 6/15/18, 3/4/18, 12/19/17, and 9/15/17. Individual #2's ISP reviews were completed on 7/31/18, 2/2/18, 10/31/17, and 7/31/17. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | 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.
The Vocational Program Specialist is responsible to ensure that the Individual Support Plan (ISP) Review includes a review of each section of the ISP, specifically review of community participation documentation.
The Vocational Program Specialists were trained in the requirements of regulation 2390.156(c)(2). (Attachment #1-Training Sheet & Attachment #2- Memo)
Individual #1¿s ISP Review Addendum was completed on 09/11/2018, addressing community participation documentation for the (06/15/2018) ISP Review. (Attachment #3 ¿ ISP Review Addendum)
Individual #1¿s ISP Review Addendum was completed on 09/11/2018, addressing community participation documentation for the (03/14/2018) ISP Review. (Attachment #4 ¿ ISP Review Addendum)
Individual #1¿s ISP Review Addendum was completed on 09/11/2018, addressing community participation documentation for the (12/19/2017) ISP Review. (Attachment #5 ¿ ISP Review Addendum)
Individual #1¿s ISP Review Addendum was completed on 09/11/2018, addressing community participation documentation for the (09/15/2017) ISP Review. (Attachment #6 ¿ ISP Review Addendum)
An e-mail was sent 09/13/2018 to the Supports Coordinator for Individual #1 ¿ notifying them of the revisions. (Attachment #7 ¿ E-mail)
Individual #2¿s ISP Review Addendum was completed on 09/12/2018, addressing community participation documentation for the (07/31/2018) ISP Review. (Attachment #8 ¿ ISP Review Addendum)
Individual #2¿s ISP Review Addendum was completed on 09/12/2018, addressing community participation documentation for the (02/02/2018) ISP Review. (Attachment #9 ¿ ISP Review Addendum)
Individual #2¿s ISP Review Addendum was completed on 09/12/2018, addressing community participation documentation for the (10/31/2017) ISP Review. (Attachment #10 ¿ ISP Review Addendum)
Individual #2¿s ISP Review Addendum was completed on 09/12/2018, addressing community participation documentation for the (07/31/2017) ISP Review. (Attachment #11 ¿ ISP Review Addendum)
E-mails were sent on 09/12/2018, to the Supports Coordinator for Individual #2 ¿ notifying them of the revisions. (Attachment #12 ¿ E-mails)
Vocational Program Specialists are in the progress of reviewing their caseloads to ensure compliance. All records will be in compliance with this regulation by 10/15/2018. |
10/15/2018
| Implemented |