Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.111(c)(10) | Individual #1's physical examination, completed on 4/13/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Effective immediately, the SC waiver physical will not be accepted as it is not compliant with 2380 regulations. A memo was added to the notice that is mailed to all individuals 2 months prior to the expiration of the physical stating that the SC physical will no longer be accepted, in addition to the physical form that is used by the agency that meets all licensing requirements. [Upon completion, the CEO or designated staff person (who is educated in the requirements of physical examinations as per 2380.111(c)(1)-(11)) shall review all individuals' physical examination documentation to ensure all required information is included as per 2380.111(c)(1)-(11). Documentation of the audits shall be kept. (AS 11/7/17)] |
10/26/2017
| Implemented |
2380.181(f) | The program specialist did not provide Individual #2's assessment, completed 12/29/16, to all plan team members, specifically the In-Home/Community Support provider. | 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). | The functional assessment was sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individual¿s ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site.[Not Acceptable. (AS 11/7/17)] [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Prior to providing individuals' assessments to individuals' plan team members the program specialist shall the review the individuals' records to include ISPs, invitation letters and other documentation to ensure the program specialist provides individuals' assessments to all plan team members. The program Director shall audit 10% of the correspondence documentation to ensure the program specialist has provided individuals' assessments to all plan team members as required. (AS 11/7/2017)] |
10/26/2017
| Implemented |
2380.186(b) | Individual #3 did not sign and date the ISP review end dated 4/4/17. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The review was reviewed with the individual on 10/12/17 and was signed. All records were audited Program Director on 10/26/17 to ensure that they were all completed. The program staff were retrained on the requirements for ISP review signatures. 10% of records will be audited by the Program Director monthly to ensure that all reviews are signed within proper time frames. Documentation of the audits will be maintained at the site. [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. (AS 11/7/17)] |
10/26/2017
| Implemented |
2380.186(d) | The program specialist did not provide Individual #2's ISP reviews end dated 11/30/16, 3/1/17, 6/1/17, and 8/30/17 to all plan team members, specifically the In-Home/Community Support provider. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | All reviews were sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individuals ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site. [Not Acceptable. (AS 11/7/17)] [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Prior to providing individuals' ISP review documentation to individuals' plan team members the program specialist shall the review the individuals' records to include ISPs, invitation letters, option to decline documentation and other documentation to ensure the program specialist provides individuals' ISP review documentation to all plan team members. The program Director shall audit 10% of the correspondence documentation to ensure the program specialist has provided individual's IPS review documentation to all plan team members as required. (AS 11/7/2017)] |
10/26/2017
| Implemented |
2380.186(e) | The program specialist did not notify all of Individual #2's plan team members of the option to decline the ISP review documentation, specifically the In-Home/Community Support provider. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | All reviews were sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individuals ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site.[POC does not address the violation and not acceptable. Immediately, the Program specialist shall notify Individual #1's In-home/community support provider of the option to decline the IPS review. Immediately, the program director shall audit all individuals' records including ISPs, invitation letter and other information to ensure the program specialist has notified all plan team members of the option to decline ISP review documentation and correspondence documentation is kept. (AS 11/7/17)] |
10/26/2017
| Implemented |