| 6400.181(a) | Individual #1 had an assessment completed on 8/26/16 and then again on 10/4/17. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Prior to provide individuals' ISP reviews to individuals' plan team members, the program specialist shall review the individual's record including option to decline documentation, invitation letters, ISPs and other documentation to ensure the program specialist provides individuals' plan team members the individuals' ISP reviews as required. At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of the correspondence documentation showing that the ISP were provided to plan team members as required. Documentation of the audits shall be kept. (4/23/18) [Not acceptable, POC does not address violation. Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of individual assessments. Within 30 days of receipt of the plan of correction, CEO or designee shall educate the program specialist on the their responsibilities of the program specialist position and the aforementioned tracking system to ensure timely completion of individuals' assessment. Documentation of the trainings shall be kept. At least quarterly for 1 year, a designated management staff person shall audit the aforementioned tracking system and a 10% sample of assessments to ensure timely completion of assessment. Documentation of the audits shall be kept. (AS 4/11/18)] |
04/10/2018
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's assessment completed 10/4/17 to the SC and plan team members on 10/10/17 for the annual ISP meeting on 10/10/17. | (f) The program specialist shall provide the assessment to the SC, 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).
| Immediately the program specialist shall review the individual's record to ensure that the file includes the invitation letters, ISPs and other documentation. This it to assure that all the required information is in the file. At least quarterly for 1 year, a designated management staff person shall audit a 25% sample of the correspondence documentation showing that the required information needed for regulations is on hand (AS 4/1/18) [Not acceptable, POC does not address violation. Immediately, the CEO or designee shall develop and implement a tracking system to ensure the program specialist provides all individuals' assessments to all plan team members, timely. Within 30 days of receipt of the plan of correction, CEO or designee shall educate the program specialist on the their responsibilities of the program specialist position and the aforementioned tracking system to ensure program specialist provides all individuals' assessments to all plan team members, timely. Documentation of the trainings shall be kept. At least quarterly for 1 year, a designated management staff person shall audit the aforementioned tracking system and a 10% sample correspondence documentation showing the program specialist provided all individuals' assessments to all plan team members, timely. Documentation of the audits shall be kept. (AS 4/11/18)] |
04/10/2018
| Implemented |