| 6400.181(f) | There is no copy of a letter from the program specialist to the team indicating that the annual assessment was sent to the team 30 days prior to the ISP meeting. There is a handwritten date on the top of the assessment document indicating that it was mailed on 10/22/23. However, there is no documentary proof via dated letter that the assessment was sent to the team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Plan to Fix the immediate problem: An assessment was re-sent to the plan team via email on 3/28/24. |
03/28/2024
| Implemented |
| 6400.195(a) | Individual#1's ISP states that the individual has a restrictive behavior plan due to behavioral issues. There is a restrictive behavior support plan dated 12/20/23 in the record dated 12/20/23 that includes a restrictive component of 2:1 staffing. There is no documentation that the restrictive plan was approved by a Human Rights Team prior to implementation, nor is there documentation that it is being reviewed at least every six months by a Human Rights Team. There is documentation of a fade plan to reduce the 2:1 staffing hours, but the dates of the fade plan (9/17/23 and 11/17/23) pre-date the implantation of the 12/20/23 restrictive behavior support plan that states there is 24-hour 2:1 staffing. When asked, agency staff relayed that the individual has supplemental habilitation approved for ambulation concerns and not behavioral concerns. However, both the ISP and the behavior support plan both state that the 2:1 staffing is in place to provide support for behavioral concerns. The prior year's plan dated 9/21/22 was a social, emotional, environmental support (SEEP) plan, so the 12/20/23 restrictive plan was newly implemented and should have had initial approval by the Human Rights Team. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | All ISPs will be reviewed quarterly by the Program Specialist to ensure they reflect the individuals present day skill levels and abilities. During Quarterly ISP Reviews the PS must review the ISP for accuracy and if changes/updates need to be made within the plan. The PS must then send notification to the SC and plan team. Program Specialist team was re-trained by the CEO on this procedure. In addition, all Ps's and Compliance team were retrained on HRC policy and procedures to ensure they understand the process of how restrictive procedures are implemented and how BSP, Support Plans and ISP¿s must all coincide. |
03/25/2024
| Implemented |