| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | The physical exam for Staff #1 was completed on 6/22/12. Her hire date was 5/30/12; therefore, her physical was not completed prior to hire date. | (a) A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
In this instance, although the physical was completed, the staff person started before we had physical custody of the report. The medical provider subsequently reported having lost the file. The immediate solution is that no staff person will start prior to our physically obtaining the required documentation. The long term process solution is as follows. Goodwill HR department and the MH/ID Compliance Monitor are establishing a process whereby all licensed positions in the agency will have required paperwork reviewed by the Compliance Monitor for accuracy and completeness prior to filing in the staff person¿s personnel file.
5. Identify licensed positions throughout the agency (completed)
6. Notify all pertinent staff and managers of the requirement (completed)
7. Review procedure with applicable HR staff (in process)
8. First staff physical due after site visit is 03/30/2013.
|
03/31/2013
| Implemented |
| 2380.113(c)(2) | The TB testing for Staff #2, completed on 6/11/12, did not include results. REPEAT from 3/5/2012. | (c) The physical examination shall include:(2) Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
The result of the TB testing for staff #2, done on 6/11/12 was read on 6/13/12, and a copy of the results were received from the physicians office on 3/21/13 (see attached.) All staff files have been reviewed for compliance as of 3/26/13.
The long term process solution is as follows. Goodwill HR department and the MH/ID Compliance Monitor are establishing a process whereby all licensed positions in the agency will have required paperwork reviewed by the Compliance Monitor for accuracy and completeness prior to filing in the staff person¿s personnel file.
9. Identify licensed positions throughout the agency (completed)
10. Notify all pertinent staff and managers of the requirement (completed)
11. Review procedure with applicable HR staff (in process)
12. First staff physical due after site visit is 03/30/2013.
|
03/31/2013
| Implemented |
| 2380.181(e)(13)(vi) | The assessment for Individual #1 did not include progress and growth in community integration. REPEAT from 3/5/2012. | (e) The assessment must include the following information: (13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Community-integration. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
A specific question regarding the progress in the area of Community ¿ Integration has been added to the Adult Training Facility Assessment form. (completed) An addendum has been added to Individual ¿1¿¿s assessment to incorporate the information. The entire assessment format is being reviewed for compliance with the language of the actual regulations rather than the LII. (in process)
The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations:
6. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13
7. Training of all Program Specialists in use of the checklist. Target: 4/15/13
8. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13)
9. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13
10. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13.
|
07/31/2013
| Implemented |
| 2380.183(7)(i) | The ISP for Individual #1 did not include his potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: (7) Assessment of the individual's potential to advance in the following:(i) Vocational programming. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
A provider request for an update to the ISP has been submitted for Individual 1, requesting that our assessment of the individual's potential to advance in Vocational Programming is included.
The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations:
11. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13
12. Training of all Program Specialists in use of the checklist. Target: 4/15/13
13. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13)
14. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13
15. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13.
|
07/31/2013
| Implemented |
| 2380.183(7)(ii) | The ISP for Individual #1 did not include his potential to advance in community involvement.
| The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: (7) Assessment of the individual's potential to advance in the following: (ii) Community involvement. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
A provider request for an update to the ISP has been submitted for Individual 1, requesting inclusion of the individuals potential to advance in Community Involvement.
Program Specialists have been retrained by the MH/ID Compliance Monitor regarding the need to review the ISP for accuracy and compliance with regulations.
The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations:
16. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13
17. Training of all Program Specialists in use of the checklist. Target: 4/15/13
18. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13)
19. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13
20. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13.
|
07/31/2013
| Implemented |
| 2380.183(7)(iii) | The ISP for Individual #1 did not include his potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: (7) Assessment of the individual's potential to advance in the following: (iii) Competitive community-integrated employment. | PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 4/4/2013
A provider request for an update to the ISP has been submitted for Individual 1 requesting that the individual¿s potential for Competitive employment is included.
The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations:
21. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13
22. Training of all Program Specialists in use of the checklist. Target: 4/15/13
23. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13)
24. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13
25. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13.
|
07/31/2013
| Implemented |
| 2380.185(b) | The outcome, increasing communication skills, for Individual #1 was not being implemented as written. | (b) The ISP shall be implemented as written. |
The ISP goal for Individual #1 was written by the Supports Coordinator as Individual I will develop communication skills. None of his current goals address communication skills. Goodwill as day program provider is not in the position to develop plans to increase comunication, which would be better created by a speech therapist or other communications expert. Should that be done, where appropriate, goals can be written to support a guided plan. A provider request for an update to the ISP has been submitted for Individual 1, see attached. The ISP will be reviewed as part of all documentation reviews and Program Specialists have been retrained by the MH/ID Compliance Monitor as to the need to insure that the ISP goals selected for Goodwill services are appropriate, and that the goals and activities conducted with the individual while at the program support the ISP goal.
The Quarterly review format as well as the goal page format have been revised to include the ISP goal as a reminder that activities at the program must be related to the ISP.
The following monitoring process will be incorporated into Goodwill¿s Quality Assurance Program to address issues of client records and compliance with regulations:
16. Development of a checklist for client documentation to be used for regular reviews of all files by the Program Specialist assigned. Target Date: 3/30/13
17. Training of all Program Specialists in use of the checklist. Target: 4/15/13
18. Annual training in documentation for all staff. (Initial training scheduled in Hbg. 7/18/13)
19. Monthly staff reviews of documentation; each Program Specialist will review selected sample of another¿s for compliance with all regulations. First review will be conducted by 4/30/13
20. Biannual reviews of sampled client documentation by the MH/ID Compliance Monitor, the Quality Assurance Director and administrative staff. First review will be conducted by 7/31/13.
|
07/31/2013
| Implemented |