| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | One bottle of Oxiver Five 16 Concentrate One-Step Disinfectant Cleaner was found unlocked under the sink in the kitchen area. One can of Valspar latex enamel paint was found unlocked in the Art Room. One bottle of China Glaze brand nail polish was found unlocked in the Program Specialists' office (door to office was not locked). | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The maintenance department will be contacted to install locking knobs on the program specialists' office door, and the supply room door. The daily chore charts for staff will be updated to include a visual inspection to ensure appropriate storage of any and all poisonous materials. In each room a reminder sheet will be posted to refresh staff of all cleaning and inspection responsibilities. The art coordinator and site staff will review and sign off on the appropriate regulations and trained on the updated cleaning responsibilities. [Program Designee will be responsible to monitor monthly to ensure that all correction activities continue to be adhered to as stated in plan of correction. JGG) |
01/31/2017
| Implemented |
| 2380.55(a) | The toilet seat in the handicapped stall of the men's bathroom was stained and dirty. | Clean and sanitary conditions shall be maintained in the facility. | The maintenance department will be contacted to replace the toilet seat mentioned. A monthly site maintenance inspection form will be devised and completed monthly to ensure any maintenance issues are addressed in a timely fashion. The program specialist and all site staff will review and sign off on the appropriate regulations. All pertinent materials will be submitted no later than January 31, 2017. |
01/31/2017
| Implemented |
| 2380.58(b) | A desk drawer in the Art Room was unlocked and contained two staple guns, a swiss army knife, a hammer and a power tool. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The keys to the mentioned drawer will be moved to the office and stored with the rest of the keys to the site. The daily chore charts for staff will be updated to include a visual inspection to ensure locked drawers and appropriate storage of any and all hazardous materials. In each room a reminder sheet will be posted to refresh staff of all cleaning and inspection responsibilities. The art coordinator and site staff will review and sign off on the appropriate regulations and trained on the updated cleaning responsibilities. All pertinent materials will be submitted no later than January 31, 2017. |
01/31/2017
| Implemented |
| 2380.67(a) | Two dining booths in the dining room had torn upholstery and worn table tops. The knob on a small painted cabinet in the dining area was stripped and pulled off in hand when inspector tried to open the cabinet. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The two dining room booths have already been replaced. The maintenance department will be contacted to replace or repair the knob on the small painted cabinet. A monthly site maintenance inspection form will be devised and completed monthly to ensure any maintenance issues are addressed in a timely fashion. The program specialist and all site staff will review and sign off on the appropriate regulations. All pertinent materials will be submitted no later than January 31, 2017. |
01/31/2017
| Implemented |
| 2380.111(a) | The most current annual physical examination for Individual #1 was dated 7/10/2015. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1's most recent physical dated 9/19/16 was collected and filed. This will be submitted with the rest of the materials on or before January 31, 2017. A policy will be written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy will state that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist. |
01/31/2017
| Implemented |
| 2380.111(c)(1) | The annual physical examination dated 2/16/2016 for Individual #4 did not include a review of medical history. | The physical examination shall include: A review of previous medical history. | Individual #4's family will be contacted and asked to request documentation of a completed review of previous medical history. A policy will be written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy will state that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist. [Program designee will review individual physical exam forms for completeness when they are received from residential providers and families. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.111(c)(7) | The annual physical examination dated 7/10/2015 for Individual #1 did not include information pertinent to the assessment of health maintenance needs, medication regimen and bloodwork. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #1's most recent physical dated 9/19/16 was collected and filed, including information pertinent to the assessment of health maintenance needs, medication regimen and blood work. A policy will be written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy will state that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist. [Program designee will review individual physical exam forms for completeness when they are received from residential providers and families. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.111(c)(9) | The annual physical examination dated 8/25/2016 for Individual #2 did not include information pertinent to allergies. | The physical examination shall include: Allergies or contraindicated medication. | Individual #2's family will be contacted and asked to request documentation of allergies or contraindicated medication. A policy will be written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy will state that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist.[Program designee will review individual physical exam forms for completeness when they are received from residential providers and families. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.111(c)(10) | The annual physical examination dated 7/10/2015 for Individual#1 did not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1's family will be contacted and asked to request documentation of information pertinent to diagnosis in case of emergency. A policy will be written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy will state that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist. [Program designee will review individual physical exam forms for completeness when they are received from residential providers and families. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(a) | Individual #4 was admitted on 9/28/2015 and the initial assessment was completed on 12/04/2015. | Each individual 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 program specialist and site director will review the regulations regarding initial assessments. In the future, during client intake, the final due date for an initial assessment will be added to a "client calendar," which will include annual and initial assessment dates, and 3 month ISP reviews. [A program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(e)(13)(i) | The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of health. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | The program specialist will redo individual 3's Annual Assessment dated 6/24/2016 to include progress and growth in the area of health. The annual assessment form will be updated to include skills information from the previous and current assessment years, and a section to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(e)(13)(ii) | The Annual Assessment dated 10/15/2015 for Individual #2 did not document progress and growth in the area of motor and communication skills. The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of motor and communication skills. The Annual Assessment dated 12/04/2015 for Individual #4 did not document progress and growth in the area of 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. | The program specialist will redo individual 2, 3, and 4's Annual Assessments as dated in the description to include progress and growth in the area of motor and communication skills. The annual assessment form will be updated to include skills information from the previous and current assessment years, and a section to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(e)(13)(iii) | The Annual Assessment dated 9/14/2016 for Individual #1 did not document progress and growth in the area of personal adjustment. The Annual Assessment dated 10/15/2015 for Individual #2 did not document progress and growth in the area of personal adjustment. The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of 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. | The program specialist will redo individual 1, 2, and 3's Annual Assessments as dated in the description to include progress and growth in the area of personal adjustment. The annual assessment form will be updated to include skills information from the previous and current assessment years, and a section to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
12/16/2016
| Implemented |
| 2380.181(e)(13)(iv) | The Annual Assessment dated 9/14/2016 for Individual #1 did not document progress and growth in the area of socialization. The Annual Assessment dated 10/15/2015 for Individual #2 did not document progress and growth in the area of socialization. The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of socialization. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. | The program specialist will redo individual 1, 2, and 3's Annual Assessments as dated in the description to include progress and growth in the area of socialization. The annual assessment form will be updated to include skills information from the previous and current assessment years, and a section to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(e)(13)(v) | The Annual Assessment dated 9/14/2016 for Individual #1 did not document progress and growth in the area of recreation. The Annual Assessment dated 10/15/2015 for Individual #2 did not document progress and growth in the area of recreation. The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of recreation. The Annual Assessment dated 12/04/2015 for Individual #4 did not document progress and growth in the area of recreation. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. | The program specialist will redo individual 1, 2, 3 and 4's Annual Assessments as dated in the description to include progress and growth in the area of recreation. The annual assessment form in the recreation section will be updated to include an area to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.181(e)(13)(vi) | The Annual Assessment dated 9/14/2016 for Individual #1 did not document progress and growth in the area of community integration. The Annual Assessment dated 10/15/2015 for Individual #2 did not document progress and growth in the area of community integration. The Annual Assessment dated 6/24/2016 for Individual #3 did not document progress and growth in the area of community integration. The Annual Assessment dated 12/04/2015 for Individual #4 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | The program specialist will redo individual 1, 2, 3 and 4's Annual Assessments as dated in the description to include progress and growth in the area of community integration. The annual assessment form in the recreation section will be updated to include an area to clearly define whether or not progress and growth has been made. The program specialist will be retrained on annual assessment requirements. [Program designee will review individual records quarterly to ensure compliance. JG 3/07/17] |
01/31/2017
| Implemented |
| 2380.183(4) | Individual #3's staffing ratio is 1:1 but there is no plan to reduce the level of staffing. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual¿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 the higher level of independence. | The program specialist will complete a fade plan for individual #3. The program specialist will be retrained on the appropriate regulations and writing fade plans. The site director will review and sign fade plans going forward. All individuals receiving 1:1 supports will have their fade plans reviewed and refreshed if necessary. This will be completed no later than January 31, 2017. |
01/31/2017
| Implemented |
| 2380.186(a) | Individual #3's three-month reviews of the ISP dated 11/24/2016 did not include the time period of 2/24/2016 to 3/23/2016. Individual #4 had two three-month reviews of the ISP dated 3/15/2016 that covered the period January, February and March 2015, but there was no ISP review covering April, May and June 2015. | 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. | The program specialist will re-do individual 3's three-month review of the ISP dated 5/24/2016 (labeled 11/24/2016 in the description) to include the appropriate dates and information. The program specialist will re-do the 2 three-month reviews of the ISP for individual (labeled as covering January through June of 2015 in the description) to include the appropriate dates and information. The program specialist will be retrained on three-month ISP reviews. Corrections will be made and submitted by January 31, 2017. |
12/16/2016
| Implemented |
| 2380.186(b) | Individual #3's three-month review of the ISP dated 11/24/2016 covering the period 3/24/2016 to 5/23/2016 was not signed by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist will review the three-month ISP review for individual #3 dated 5/24/2016 (labeled in the description as 11/24/2016) with individual #3, offering opportunity for review and comment and signing. The program specialist will be retrained on three-month ISP reviews. The site director will review and sign three-month ISP reviews to ensure completion and appropriate signing. |
01/31/2017
| Implemented |