| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(10) | The Program Specialist did not complete monthly ISP reviews from November 2017 to March 2018 for Individual #1 . | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes. | The individual #1 was temporarily relocated to another provider in November 2017 after an altercation with another individual and was unable to return to this home. CLASS was readying another home which he moved to in April 2018. This was a circumstance that had not occurred before and Program Specialist was not aware that this responsibility continued even while he was temporarily located. The Training Coordinator will retrain both Program Specialists regarding this responsibility as well as the others in this job category. In addition, the Quality Compliance and Privacy Officer will conduct periodic audits (every 6 months) of the individuals' ISP activity and documentation completion.[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] |
10/01/2018
| Implemented |
| 6400.113(a) | Individual #1 was instructed in annual fire safety training on 3/6/17 and then again on 4/4/18. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The individual #1 was temporarily relocated to another provider in November 2017 after an altercation with another individual and was unable to return to this home. CLASS was readying another home which he moved to in April 2018 and he was retrained within days of moving into his new home. The self assessment was completed by the Quality Compliance and Privacy Officer and Coordinator of Residential Homes in May 2018 and all other individuals in licensed homes had acquired their annual fire safety training within the 365 days requirement. The Quality Compliance and Privacy Officer and/or the Coordinator of Residential Homes will continue to conduct audits every year to ensure all individuals are trained annually in general fire safety.[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] |
09/18/2018
| Implemented |
| 6400.186(a) | The Program Specialist completed an ISP review for Individual #1 on 10/12/17 and then again on 4/12/18. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The individual #1 was temporarily relocated to another provider in November 2017 after an altercation with another individual and was unable to return to this home. CLASS was readying another home which he moved to in April 2018. This was a circumstance that had not occurred before and Program Specialist was not aware that this responsibility continued even while he was temporarily located. The Training Coordinator will retrain both Program Specialists regarding this responsibility as well as the others in this job category. In addition, the Quality Compliance and Privacy Officer will conduct periodic audits (every 6 months) of the individuals' ISP activity and documentation completion.[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] |
10/01/2018
| Implemented |
| 6400.186(d) | The Program Specialist did not provide Individual #1's ISP reviews, completed 7/12/18, 10/12/17, 4/12/18 and 6/25/18 to the plan team members: [Repeat Violation 9/12/18, et. al.] | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The individual #1 was temporarily relocated to another provider in November 2017 after an altercation with another individual and was unable to return to this home. CLASS was readying another home which he moved to in April 2018. This was a circumstance that had not occurred before and Program Specialist was not aware that this responsibility continued even while he was temporarily located. The Training Coordinator will retrain both Program Specialists regarding this responsibility as well as the other responsibilities in this job category. In addition, the Quality Compliance and Privacy Officer will conduct periodic audits (every 6 months) of the individuals' ISP activity and documentation completion.[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/2/18)] |
10/01/2018
| Implemented |