| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Individual #1 received fire safety training on 8/23/16. There was no documentation of the 2015 fire safety training. | 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. | Individual #1 received the fire safety training in 2015, but did not sign the attendance sheet. Attendance sheet for fire safety training has been revised to include each client's name beside the signature line to insure each individual signs as required for documentation purposes. |
04/28/2017
| Implemented |
| 2390.151(a) | REPEATED VIOLATION - 5/12/16. Individual #1's 9/26/16 assessment was completed late. The previous assessment was completed on 9/1/15. | 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 program specialist is preparing a calendar for a twelve month period that will show every assessment due date for the year. This will simplify the monitoring process and insure that the assessments are completed within the annual time frame requirement. |
04/28/2017
| Implemented |
| 2390.151(f) | Individual #1's 9/26/16 assessment was sent to plan team members on 9/26/16 for a 10/13/16 Individual Support Plan meeting. | 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 program specialist is preparing a calendar for a twelve month period that will show every assessment due date for the year. This will simplify the monitoring process and insure that the assessments are completed and sent at least 30 days in advance of the meeting. In addition, the MH/ID Compliance Monitor has retrained the program specialist to instruct SC's that the meeting date, once scheduled, can not be changed to a date that interferes with the 30 day requirement. |
04/28/2017
| Implemented |
| 2390.156(c)(2) | Individual #1's 7/14/16, 10/13/16, and 1/19/17 and Individual #2's 7/14/16, 10/13/16, and 1/19/17 Individual Support Plan (ISP) Reviews did not include a review of Indiviudal #1 and #2's social, emotional, environmental needs plan. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The MH/ID Compliance Monitor trained the program specialist regarding the need to include discussion of the use of the SEEN plan in each quarterly rather than only a checklist. The program specialist has attached addendums to the most recent quarterly reviews for both individuals and is completing a review of all other client files for compliance. |
04/28/2017
| Implemented |