Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.173(1)(ii) | Race was missing from Individual #3's record. Eye color was missing from Individual #2. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The Program Specialist has corrected the record for individual #2 to include eye color and #3 for race. Attachment H (Ind #2 Admission Record) I (Ind. #3 Admission Record). To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has provided training on the process. Attachment K - Training Record |
07/02/2015
| Implemented |
2380.173(1)(iv) | Religious affiliation was missing from Individual #2's record. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | The Program Specialist has corrected the record for individual #2 to include Religious affiliation. Attachment H (Ind #2 Admission Record) To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has trained all staff in the process. Attachment K Training Record |
07/02/2015
| Implemented |
2380.173(9) | Individual #3's Individual Support Plan (ISP) stated that they were on a low sodium diet. Individual #3's physical had them on a reduced carbohydrate diet and their medication administration record had them on a 1400 diabetic diet. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Residential Medical Coordinator accompanied Individual # 3 for her annual physical where they obtained the most current dietary guideline for Ind #3. Attachment J (Updated Physical for #3). The Medical Coordinator provided the Support Coordinator with the current physical. The Program Specialist included the information in the new assessment and provided the assessment to the team. Future Occurrence: The Program Executive Secretary will review all physical to assure they are complete then the Program Specialist will review it to assure there are no discrepancies. The Program Supervisor has trained responsible staff. Attachment K (Training Record) |
07/06/2015
| Implemented |
2380.181(e)(12) | The assessments for Individuals #1 and #3 did not contain recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Correction: Who: The Program Specialist What: Assessments have been amended to include specific areas of training, vocational programming and competitive community-integrated employment and provided to the individuals Teams. Attachment F-6 (#1 Assessment page 6) and G-6 (#3 Assessment page 6). Future Occurrences. The assessment format has been updated to include and will provide documentation of individual's potential and recommendations for specific areas of training,vocational programming and competitive community integrated employment. It will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. |
07/08/2015
| Implemented |
2380.181(e)(13)(iv) | The assessment for Individual #3 did not include progress and current level 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 Program Specialist has corrected the record for individual #2 to include eye color and #3 for race. Attachment H (Ind #2 Admission Info) I (Ind. #3 Admission Info). To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has provided training of the process to responsible staff. Attachment K - Training Record |
07/08/2015
| Implemented |
2380.181(e)(13)(vi) | The assessments for Individuals #1 and #3 did not include their progress and current level 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. | Correction: Who: The Program Specialist What: Individual #1 & #3¿s assessments has been amended to include their progress and current level in community-integration and was provided to the Teams. Attachment F-6 (#1 Assessment) G -8 (#3 Assessment). Future Occurrences. The assessment format has been updated to include and will provide documentation of individual's progress and current level and will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. |
07/08/2015
| Implemented |
2380.183(7)(i) | The Individual Support Plans (ISPs) for Individuals #1 and #3 did not include an assessment of their 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: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Correction: Responsible: The Program Specialist What: Assessments have been amended to include Vocational Programming and has been provided to the team. Attachment F-6 (#1 Assessment page 6) and G-4 (#3 Assessment page 4). Future Occurrences: The Program Specialist has updated the assessment. The format has been updated to include their potential to advance in vocational programming and will provide documentation of individual's potential. It will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will be review every 3 months this section of the ISP. |
07/08/2015
| Implemented |
2380.183(7)(ii) | The Individual Support Plan (ISP) for Individual #1 did not include an assessment of their 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: Assessment of the individual¿s potential to advance in the following: Community involvement. | Correction: Person Responsible: Program Specialist What: The Assessment has been amended to include Community Involvement. Attachment F -7 (#1 Assessment page 7) and it has been provided to the team. Future Occurrences. The assessment format has been updated to include Community Involvement and will provide documentation of individual's potential and will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. |
07/08/2010
| Implemented |
2380.183(7)(iii) | The Individual Support Plans (ISPs) for Individuals #1 and #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. | Correction: Responsible: The Program Specialist What: Individual #1 and #3 Assessments have been amended to include Competitive Community Integrated employment. Attachment F-4 (#1 Assessment page 4) and G-4 (#3 Assessment page 4) and provided to the team. Future Occurrences. The assessment format has been updated to include competitive employment and will provide documentation of individual's potential and will be provided to team members at least 30 days prior to ISP meeting date.The Program Specialist will review this section of the ISP every 3 months. |
07/08/2015
| Implemented |
2380.186(c)(2) | The Individual Support Plan (ISP) reviews for Individual #3 did not review their 60 minutes of unsupervised time or their Social, Emotional and Environmental plan. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Program Specialist will include a review of Ind # 3's use of unsupervised time as well as the SEE plan in the scheduled quarterly to be completed. The Program Specialist notified the Support Coordinator requesting an ISP update for identified issues. Attachment A: ISP 3 month review B: Notice to SC The Program Specialist Supervisor has trained the Program Specialist to assure that all components of the ISP are reviewed. Attachment C: Training Log |
07/09/2015
| Implemented |
2380.186(e) | The program specialist for Individual #1 did not notify their supports coordinator of the option to decline the Individual Support Plan (ISP) review documentation. The program specialist for Individual #2 did not notify their mother of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist has notified the respective Individual's teams of the option to decline ISP reviews . Attachments D & E: Copy of Letters. The Program Specialist will continue to include the option to decline in all future contacts. |
07/08/2015
| Implemented |