| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was a closet door off the track in the apartment. | Floors, walls, ceilings and other surfaces shall be in good repair. | A repair request was submitted to Bancroft¿s Facilities department. This repair request was completed on 2/11/17. |
04/03/2017
| Implemented |
| 6400.77(b) | The homes first aid kit was missing scissors and a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | All first-aid kits have been updated and checked to ensure that they contain scissors and a thermometer. The Program Managers/Specialists are responsible for completing a Health and Safety Checklist each month and submitting the Checklist electronically to the Risk Management department. One aspect of this Checklist is examining the first-aid kit to ensure that all necessary materials are present and not outdated. |
04/03/2017
| Implemented |
| 6400.141(a) | Individual #4's most recent annual physical examination was dated 11/3/16 and the prior one was dated 8/11/15. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Managers/Specialists are responsible for tracking the dates of each individual¿s annual physical examination. It is their responsibility to ensure that each individual receives a physical within 12 months of their previous physical examination. As a result of multiple refusals from the individuals in the Parenting Program, the Program Manager/Specialist will schedule a physical examination for the individual at least 3 months prior to the due date of the physical examination. This will allow for the possibility of multiple refusals as well as leaving an adequate timeframe to work with the individual to remain in compliance. There will be a team meeting scheduled within the next 30 days to develop a desensitization plan for Individual #4.. |
04/03/2017
| Implemented |
| 6400.141(c)(10) | Individual #4's annual physical examination, dated 11/3/16, did not indicate whehter or not they were free of communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #4¿s annual physical has been updated. The Nurse and/or Health Care Coordinator is responsible for ensuring that the appropriate physical form is taken and completed in its entirety at each annual physical and will be reviewed within 48 hours of the physical examination. Please see Attachment number 7 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.141(c)(14) | Individual #4's annual physical examination, dated 11/3/16, did not list information pertainent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #4¿s annual physical has been updated. The Nurse and/or Health Care Coordinator is responsible for ensuring that the appropriate physical form is taken and completed in its entirety at each annual physical and will be reviewed within 48 hours of the physical examination. Please see Attachment number 7 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.142(d) | Individual #4's annual dental examination did not indicate if there was a cleaning performed. | The dental examination shall include teeth cleaning or checking gums and dentures. | Individual #4 attended an annual dental exam on 2/22/17 which documents that a cleaning was performed. Please see Attachment number 6 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(viii) | Individual #4's annual assessment, dated 7/6/16, did not include progress and growth in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Individual #4¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 5 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #4's annual assessment, dated 7/6/16, did not include 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. | Individual #4¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, progress and growth. Please see attachment number 5 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.181(e)(14) | Individual #4's annual assessment, dated 7/6/16, did not include ability to swim or knowledge of water safety. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #4¿s annual assessment has been updated. Going forward, the Program Managers/Specialists are responsible to update their specific individual¿s assessments and ensure that all necessary components of the annual assessment are included; specifically, the individual¿s ability to swim or knowledge of water safety. Please see attachment number 5 for supporting documentation. |
04/03/2017
| Implemented |
| 6400.217 | Individual #4's record did not contain a release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Bancroft¿s official annual Consent Packet was re-presented and signed by Individual #4. The Consent Packet addresses the consent of the individual for release of information, including photographs, to persons not otherwise authorized to receive it. This Consent Packet is presented for signature at the annual ISP review to each individual and/or their guardian. Please see Attachment number 4 for supporting documentation. |
04/03/2017
| Implemented |