Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.163(b) | Individual #1's psychiatric review's did not include medication and dosages for the 2/6/15 and 12/15/14 appointments. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. | 1. LSS Medical Coordinator is responsible to educate, oversee & ensure the individual¿s psychiatric reviews include medication and dosages for all psychiatric sessions/appointments.
1a. LSS Residential Service Worker (RSW¿s) are responsible to attached current physician order sheets for the physician to review and sign off on. If the physician choses to keep a copy of current orders, a second copy must be made and attached to the summary.
2. LSS Medical Coordinator is responsible to review all summaries as they are turned in to assure the physician¿s orders are attached. If an appointment summary is submitted to the medical department without the physician orders attached, the staff (RSW) will be contacted by the Medical Coordinator to provide the physician orders immediately to be filed.
3. LSS Medical Coordinator is responsible to educate and train the house staff (RSW¿s & House Supervisors) in regards to the process in having current physician orders attached to the appointment summaries for the physician to review and sign off on via email and Care tracker (see attached documentation).
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05/07/2015
| Implemented |
6400.181(e)(7) | Individual #1's assessment did not include knowledge of the danger of heat sources and the ability to sense and move away quickly. | 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. | 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s knowledge of the danger of heat sources and the ability to sense and move away quickly.
LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress if applicable.
2. LSS Case Coordinators corrected Individula¿s#1 assessment summary specifying the individual¿s knowledge of the danger of heat sources and the ability to sense and move away quickly.
(See attached assessment).
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05/07/2015
| Implemented |
6400.181(e)(12) | Individual #1's assessment did not include recommendations for specfic area's of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. LSS Case Coordinators is responsible to ensure the assessments include recommendations for specific areas of training, programming, and services.
2. LSS Case Coordinators corrected Individula¿s#1 assessment summary specifying the individual¿s recommendations for specific areas of training, programming, and services
(See attached assessment).
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05/07/2015
| Implemented |
6400.181(e)(13)(ii) | Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in motor and communication skills. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year.
LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress.
2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to motor and communication skills (see attached assessment).
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05/07/2015
| Implemented |
6400.181(e)(13)(iv) | Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in personal adjustment. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year.
LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress.
2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to personal adjustment (see attached assessment).
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05/07/2015
| Implemented |
6400.183(6)(ii) | Individual #1's ISP did not contain a protocol to eliminate the use of restrivtive procedures and a protocol for addressing the underlying causes or antecedents of the behavior. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures and a protocol for addressing the underlying causes or antecedents of the behavior via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder.
2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) identifying the revisions that needed to be made to the ISP (see attached email).
2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email.
3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to use of restrictive procedures and a protocol for addressing the underlying causes or antecedents of the behavior is included and/or correct.
4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder.
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05/11/2015
| Implemented |
6400.183(6)(iii) | Individual #1's ISP did not include a protocol to eliminate the use of restrictive procedures including the method and timeline for eliminating the use of restricitive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures including the method and timeline for eliminating the use of restrictive procedures via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder.
2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) with the BSP attached specifically identifying what needed corrected in the ISP (see attached email).
2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email.
3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to the method & timeline for eliminating the use of restrictive procedures is included and/or correct.
4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder.
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05/11/2015
| Implemented |
6400.183(6)(iv) | Individual #1's ISP did not include a protocol to eliminate the use of restricitive procedures including a protocol for intervention or redirection without utilizing restricitive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. | 1. LSS Behavioral Specialist is responsible to ensure the individual¿s ISP contains the protocol to eliminate the use of restrictive procedures including a protocol for intervention or redirection without utilizing restrictive procedures via email notifications to the individual¿s SC¿s. LSS¿s Behavioral Specialist will file all email correspondence in the individual¿s BSP binder.
2. LSS¿s Behavioral Specialist sent an email on 4/28/15 at approximately 8:50am to Individual #1¿s Support Coordinator (Trudy M.) with the BSP attached specifically identifying what needed corrected in the ISP (see attached email).
2a. LSS¿s Case Coordinator is responsible to follow-up with the Individual #1¿s SC ensuring the corrections were made via email.
3. LSS¿s Behavioral Specialist is responsible during annual ISP meetings to read the ISP behavior support section to ensure that the information pertaining to the method & timeline for eliminating the use of restrictive procedures is included and/or correct.
4. LSS Behavioral Specialist will request via email that the individual¿s SC write in the Individual¿s ISP see attached BSP. LSS Behavioral Specialist will then submit the entire plan to be attached to the consumers ISP to ensure all BSP information is included in the Individual¿s ISP. All correspondences will be filed in consumers BSP binder. |
05/11/2015
| Implemented |
6400.183(7)(iii) | Individual #1's ISP did not include the assessment of the indivduals potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | 1. LSS Case Coordinator is responsible to ensure the individual¿s ISP identifies the individual¿s potential to advance in vocational programming via meetings and via email notifications to the individual SC¿s. LSS Case Coordinators will file all email correspondence in the individual¿s Program Book.
LSS Case Coordinator emailed the individual¿s SC on 5/7/15 requesting the information pertaining to the individual¿s potential to advance in vocational programming in the Individual¿s ISP (see attached email correspondence).
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05/11/2015
| Implemented |
6400.195(d) | Individual #1's restricitive procedure plan shall be reviewed, approved, and signed and dated by the chairperson of the restricitive procedure review committee and the program specialist. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| 1. LSS Behavior Specialist is responsible to ensure the individual¿s restrict procedure plan is reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist prior to use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least 6 months.
2. The Behavior Support Plan was modified to have a signature location directly on the plan for the HR committee chair to sign the document. (See attached signature page).
3. LSS¿s Behavior Specialist will have Individual #1¿s BSP re-signed utilizing the BSP revised format (see attached signature page).
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05/11/2015
| Implemented |