| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | Individual #1 requires 2:1 staffing during waking hours; however on 4/15/14, between 5:20pm and 6:45 pm this individual was provided 1:1 staffing. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | This violation occurred due to the error in judgment of the Site supervisor in ensuring that staffing ratio was maintained at all times during the individual's transportation back home on a visit.
This Site supervisor was retrained on 04/28/14 on the ISP, staffing ratios and supervision. By 05/19/14, all Site Staff were retrained on incident management, neglect and abuse; how to identify any disparity in ISP ratio and how to proceed when inconsistency is identified.
The Site Supervisors and Program Specialist will ensure that staffing ratio is maintained at all times, even during transportation for family visit. The Residential Director will ensure strict compliance to this. |
04/28/2014
| Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | This violation was corrected on 08/09/14 when the Residential Director replaced the missing first aid manual for the first aid kit in question.
Site supervisors have in serviced all staff on ensuring that all the necessary contents required per regulation are maintained at all times for all first aid kits. Site supervisors will include first aid kit checks as part of their weekly site checks and will replace the manual immediately on noticing it missing. The Residential Director will monitor the process to ensure compliance.
|
08/09/2014
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment dated 7/12/13, did not identify or list recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An addendum assessment summary was completed on 06/06/2014 to include recommendations for specific areas of training, programming and services for Individual #1. This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment dated 7/12/13, did not list progress and growth in the areas of health, 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: 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: Motor and communication skills. | An addendum assessment summary was completed on 06/06/2014 to include progress and current level in the areas of Health and Motor and communication skills for Individual #1.This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment dated 7/12/13, did not list progress and growth in the areas of activities of residential living and 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: Activities of residential living. 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. | An addendum assessment summary was completed on 06/06/2014 to include progress and current level in the areas of Residential living and Personal adjustment for Individual #1.This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment dated 7/12/13, did not list progress and growth in the area of 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 assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | An addendum assessment summary was completed on 06/06/2014 to include progress and current level in the areas of Socialization and Recreation for Individual #1. This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 7/12/13, did not list progress and growth in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
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. | An addendum assessment summary was completed on 06/06/2014 to include progress and current level in the areas of financial independence and managing personal property for Individual #1.This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 7/12/13, did not list 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. 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. | An addendum assessment summary was completed on 06/06/2014 to include progress and current level in the areas of Community Integration and knowledge of water safety and ability to swim for Individual #1. This assessment is not intended to supplant the annual assessment date for this individual based on their admission date.
Going forward, the Program Specialist will ensure all the relevant sections as specified by 6400 regulations are captured in Individuals annual assessments. All completed assessments will be reviewed for content and accuracy by the Residential Director before they are sent out to the team.
|
06/06/2014
| Implemented |
| 6400.181(f) | Individual #1's assessment, dated 7/12/13, was not sent to the supports coordinator. | (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).
| The assessment in question was sent to the SC however there was no documentation to support the SC receiving the assessment.
The most current assessment for this individual was sent out on 07/08/2014 to ensure that the team received it at least 30 days before the ISP meeting date.
A spreadsheet has been developed which captures the ISP review dates, ISP meeting dates, and expected dates of assessment and ISP review send out. In addition, the Program Specialist will add ticklers to her outlook calendar, which will be shared with the Residential Director in order to have reminders as to when the required documentation should be sent out. The spreadsheet will be monitored for compliance by the Program Specialist and the Residential Director will supervise and ensure that the assessments are sent out at least 30 days prior to the ISP meeting date.
|
07/08/2014
| Implemented |
| 6400.185(b) | Individual #1's ISP dated 11/13/13 identifies behavioral supports as a need. The behavioral support plan is dated 9/8/13 and recommends that Individual #1 will comply without incident when transitioning from one activity to the next; the plan also recommends that Individual #1 will be able to seek staff's attention appropriately by using gestures and verbalizations. Neither the monthly nor the three month ISP reviews identify that the behavior support plan has been implemented. In addition, the behavioral support plan recommends that "The site supervisory team should assure that staff working with the individual is trained in implementing the plan". Staff A was not trained in the plan.
| The ISP shall be implemented as written. | A behavior support plan tracking sheet for Individual #1 was developed on 06/05/14, which is now being used to track the behavior of the individual especially as it relates to transitioning from one activity to the other. In addition, on 06/26/2014, the Behavior Specialist conducted training for staff A as well as other staff members on how to implement the Behavior Plan of the individual.
Going forward, the Program Specialist will ensure that the ISP is implemented as written by ensuring that all sections of the ISP relating to the chapter under review are implemented. All monthly and Quarterly reviews will now document the implementation of the Behavior Support Plan. The Residential Director will monitor this process to ensure compliance.
|
06/26/2014
| Implemented |
| 6400.186(c)(3) | On 4/18/14, Individual #1 alleged sexual abuse. An ISP review was completed on 5/13/2014, yet the program specialist did not make recommendations to the supports coordinator to modify this individual's ISP to include supports associated with the allegations. The 5/13/14 ISP review did not mention the 4/18/14 incident. | The ISP review must include the following: The program specialist shall document a change in the individual's needs, if applicable. | The ISP review in question was updated to include information regarding the unfounded sexual abuse allegation and recommendation for the peculiar statements by the individual to be updated in her ISP. This updated ISP review was sent out to the SC on 06/06/2014.
Going forward, the Program Specialist will ensure that all ISP reviews include all pertinent information relating to the supports provided to the individual. In addition, all necessary recommendations will be made to the Supports Coordinator as applicable for updates in the ISP. The Residential Director will review all ISP reviews for content and accuracy before they are sent out to the SC and other plan team members.
|
06/06/2014
| Implemented |