Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.89(b) | During the fire drill conducted today about 5 or more staff from another building that aren't counted in the staffing ratio for the day program, came over to assist with the fire drill. | Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average. | |
| Implemented |
2380.127(a)(4) | Staff #2's medication administration training expired in January 2015. Staff #2 continued to administer medications in February, March, and April 2015. Staff #4 did not complete the entire annual medication administration training. Staff #4 only completed observations. She has not been certified to administer medications since 6/12/14 and she has been administering medications. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: A staff person who meets the criteria in § 2380.128 (relating to medication administration training), for the administration of oral, topical and eye and ear drop prescription medications and insulin injections. | |
| Implemented |
2380.128(a) | Staff #2 had annual medication administration completed on 1/13/14 and not again yet. She was due on 1/13/15 and annual licensing survey was completed on 4/6/15. Staff #4 was due for her annual medication administion training on 6/12/14 but has not completed it yet. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | |
| Implemented |
2380.181(d) | The program specialist did not sign and date the assessment for Individual #2. | The program specialist shall sign and date the assessment. | The assessment has been signed and dated. The Manager of Community Skills has retrained the Program Specialists regarding the requirement of signatures and dates on all documentation. This requirement for all legal documentation is now emphasized in the mandatory training on Billing and Documentation as well. The Program Specialist has reviewed all files to ensure signatures and dates are on all applicable documents. |
07/31/2015
| Implemented |
2380.181(e)(5) | The assessment for Individual #1 did not include their ability to self-administer medications. | The assessment must include the following information: The individual¿s ability to self-administer medications. | The Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) ability to identify medication, tell correct time, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(i) | The assessment for Individual #1 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) routine medical assessments or appointments, general health stable, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(ii) | The assessments for Individuals #1 and #3 did not contain progress and growth 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. | The Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) dexterity, ability to make needs and wants known, ability to navigate safely through an area, etc.. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(iii) | The assessment for Individual #1 did not contain progress and growth 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. | The Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) the individual¿s ability to interact successfully with the community and others around him etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(iv) | The assessment for Individual #1 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) ability to successfully demonstrate social skills in the community. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(v) | The assessment for Individual #1 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialist regarding the need for information in this section, including (example) interest in participating in recreational activities, preferred recreation, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.181(e)(13)(vi) | The assessment for Individual #1 did not contain progress and growth in 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 Manager of Community Skills has retrained the Program Specialists regarding the need for information in this section, including (example) amount of time tolerated in community environments, willingness to participate in community activities, etc. The assessment form has been revised to match the exact language of the regulation. The Program Specialist is attaching an addendum with the required information and is reviewing files to determine if current assessments require addendums to address all required components. |
07/31/2015
| Implemented |
2380.182(d)(4) | There was no documentation that an Individual Support Plan (ISP) invitation was sent to team members for Individual # 2. | The plan lead shall develop, update and revise the ISP according to the following: An invitation shall be sent to plan team members at least 30 calendar days prior to an ISP meeting. | The Manager of Community Skills has retrained the Program Specialists regarding the requirement of an ISP invitation being maintained in the file. Should an invitation not be forthcoming from the SC, the Program Specialist will verify in writing the date/time of the meeting as scheduled, requesting confirmation from the SC with a copy of the invitation. |
07/31/2015
| Implemented |
2380.183(7)(iii) | The Individual Support Plan (ISP) for Individual #3 did not include an assessment of their 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: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | The ISP for Individual #3 contains a statement in the Educational/Vocational section that Individual #3 expresses no interest in having an employment goals at this time due to his retirement age and poor eyesight¿ . Individual #3 is 66 years old and now legally blind in addition to significant functional limitations. However there is no corresponding statement in the Employment/Volunteer information section. Supports Coordinators will be advised at all ISP meetings that the section must be addressed to meet regulatory compliance. The Manager of Community Skills has retrained the Program Specialists regarding the requirement this information is contained in the ISP. The Program Specialist is reviewing individual ISPs to determine if changes must be requested of the SC. |
07/31/2015
| Implemented |
2380.187 | Individual #2's Individual Support Plan (ISP) meeting was held on 11/11/14 and not sent to team members until 1/9/15. Individual #1's ISP meeting was held on 9/9/14 and was not sent to team members until 10/28/14. | A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP annual update and ISP revision meetings. | The Manager of Community Skills has retrained the Program Specialist regarding the requirement and the necessity of contacting the SC to remind him/her of the need for Goodwill to have the ISP within 30 days. Licensing inspectors recommended this reminder contact be made as soon as possible after the ISP meeting rather than wait until closer to the 30 day limit, and documented appropriately, Program Specialists have been instructed to make this a regular practice. |
07/31/2015
| Implemented |