Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2390.60(a) | The site did not have a first aid area specifically for first aid purposes. | (a) A facility shall have a first aid area that is separate from the work area. | Provider has creating a separate first aid area that is used exclusively for first aid. The program specialist will review this area on a monthly basis to ensure that it is used exclusively for first aid treatment starting 1/31/14. |
12/20/2013
| Implemented |
2390.151(e)(9) | The lifetime medical history for individual # 3 was incomplete. | (e) The assessment must include the following information: (9) Documentation of the client's disability, including functional and medical limitations. | Each assessment will include complete lifetime medical histories using the correct terminology or document our efforts to obtain the information. Individual #3's assessment was updated to include the lifetime medical history. The program specialist will audit all of the participants assessments to ensure that a lifetime medical history is included by 1/31/14. |
12/20/2013
| Implemented |
2390.151(e)(12) | Individual # 2's assessment dated 6/30/13 and individual's # 3 assessment dated 10/2/12 did not have recommendations for specific vocational training. | (e) The assessment must include the following information: (12) Recommendations for specific areas of vocational training or placement and competitive community-integrated employment. | Provider assessment will include specific areas of vocational training and a specific competitive job title if community employment is recommended. Individual #2 and Individual #3's assessment was updated to include specific vocation training. The program specialist will audit all of the participants assessments to ensure that all required elements of the assessment are included by 1/31/14. The audit will be performed on a monthly basis, on all updated and new assessments to ensure that are complete. |
12/20/2013
| Implemented |
2390.151(f) | Individual # 4 was admitted 6/19/13 and the assessment was completed on 7/17/13. The plan meeting was held on 7/9/13. | (f) The program specialist shall provide the assessment to the SC or plan lead, 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). | Program Specialists will provide the assessment to plan team members at least 30-calendar days prior to an annual meeting. The Program Director will review the assessments with the Program Specialist to ensure that the assessment is forwarded timely, starting 1/31/14. |
12/20/2013
| Implemented |
2390.156(a) | Individuals #1 and #2 quarterly ISP reviews did not report progress for their outcomes. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. | Program Specialists will comment on the quality of work and progress on outcomes. Individual #1 and #2's quarterly ISP's for December, 2013 will reflect an accurate review of their progress on the ISP outcomes. The Program Director will review all participants quarterly ISP reviews to ensure they accurately reflect the participants progress starting 1/31/14. |
12/20/2013
| Implemented |