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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(a) | Individual #1 was not informed of the following rights: right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice; right to unrestricted mailing privileges; and right to practice the religion or faith of the individual's choice. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | The Individual Rights Statement was updated on 4/10/14 to include information pertaining to individual rights surrounding scheduled and/or unscheduled visitors, unrestricted mailing privileges, practice of religion or faith of the individual¿s choice and communication, association and/or private meetings with family and persons of the individuals own choice. The signed revised Individual Rights Statement for individual #1 will be submitted as confirmation of WRC¿s compliance with regulatory requirements. The revised Individual Rights Statement shall continue to be used to inform participants of their rights upon admission and annually thereafter. |
04/10/2014
| Implemented |
| 6400.181(f) | The program specialist did not send the assessment dated 6-26-13 for individual #1 to the plan team at least 30 calendar days prior to the ISP meeting. | (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).
| Individual #1 was admitted to WRC on 5/26/13. An initial assessment was completed on 6/26/13. This assessment was not shared with the SC or plan team. Individual #1¿s initial ISP Meeting was held on 8/20/13. An updated assessment was completed on 7/20/13 by WRC Program Specialist; the assessment was also sent to plan team members on this date, however, because this staff is no longer with WRC we are unable to access email verification of sent items. We are therefore unable to provide written confirmation showing that the assessment was sent exactly 30 days prior to the first ISP Meeting post admission. Our current practice is to print and file documentation of all emails sent to SC¿s and/or plan team members in a Communication Log as our confirmation of regulatory compliance. In an effort to avoid further occurrence of this violation we have decided to improve upon our current practice by also updating the Assessment Cover Page, or Declination Page; it will now be directly addressed to and sent to the SC, and all other plan team members will be added to the bottom left as a Carbon Copy (Cc:) to identify additional recipients of the letter. As an added back up, our Senior Program Specialist has been assigned the responsibility of monitoring and tracking the completion of all assessments within required timeframes, as well as the sharing of all assessments with required parties. |
04/18/2014
| Implemented |
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