| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(h) | Records of orientation and training for Staff #1, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, were not kept. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Program Specialist will maintain a spreadsheet for all staff orientation and training requirements. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Principal and CEO will have monthly meetings to discuss staffing needs and requirements. Program Specialist will continue to monitor and CEO will oversee that no staff will work with individuals without required training and documentation. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.53(b) | There was liquid hand soap in the men's bathroom that was not in the original labeled container. | Poisonous materials shall be stored in their original, labeled containers. | Hand soap was immediately removed and new hand soap was placed in the men's bathroom in original labeled container. Staff, Program Specialist and CEO will continue to monitor and assure all future compliance. |
01/31/2020
| Implemented |
| 2380.70(b) | The first aid area did not contain a pillow. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | Pillow was placed back in first aid area immediately. Staff, Program Specialist and CEO will assure all future compliance with this regulation. |
01/31/2020
| Implemented |
| 2380.111(a) | Individual #1 was admitted on 12/17/18, and did not have a physical examination within 12 months prior to the date of admission. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 does have an appropriate current physical on file. Program Specialist will develop an individual physical spreadsheet with all pertinent and required dates to assure a timely and successful completion of all individual physicals. Program Specialist will receive remediation training on individual physicals, regulations and time frames. Program Specialist will assure all future compliance an CEO will provide oversight. |
01/31/2020
| Implemented |
| 2380.111(c)(5) | Individual #2's most recent Mantoux test occurred on 3/04/15. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. | Program Specialist will receive remediation training regarding TB/Mantoux testing in terms of regulations and requirements. Program Specialist will attain documentation of recent chest X-ray in 2019 from family and keep in her file. Program Specialist will assure all future compliance and CEO will provide ongoing oversight. |
01/31/2020
| Implemented |
| 2380.113(a) | The current physical examination for Staff #1 was late. The current examination occurred on 5/11/18 and the previous was on 12/08/15. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #1 did have a timely completion on her most recent physical so this will be assured at her next required physical. Program Specialist and Safe Environment Coordinator will develop a staff physical spreadsheet with all pertinent and required dates to assure a timely and successful completion of all staff physicals and TB tests. Program Specialist will assure all future compliance an CEO will provide oversight. |
01/31/2020
| Implemented |
| 2380.113(c)(2) | The initial physical examination on 12/08/15 for staff #1 did not include tuberculin testing by Mantoux method. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Staff #1 did have a TB test done on her most recent physical so this will be assured at her next required physical. Program Specialist and Safe Environment Coordinator will develop a staff physical spreadsheet with all pertinent and required dates to assure a timely and successful completion of all staff physicals and TB tests. Program Specialist will assure all future compliance an CEO will provide oversight. |
01/31/2020
| Implemented |
| 2380.181(a) | Individual #1 was admitted on 12/17/18 and did not have an initial assessment completed within 1 year prior to or 60 calendar days after admission to the facility. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(12) | The assessment completed on 11/08/19 for Individual #2 did not contain recommendations for trainings, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(i) | The annual assessment dated 11/08/19 for individual #2 did not contain: 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: Health. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(ii) | The annual assessment dated 11/08/19 for individual #2 did not contain: The individual's progress over the last 365 calendar days and current level in the following areas: 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: Motor and communication skills. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(iii) | The annual assessment dated 11/08/19 for individual #2 did not contain: The individual's progress over the last 365 calendar days and current level in the following areas: 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: Personal adjustment. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(iv) | The annual assessment dated 11/08/19 for individual #2 did not contain: 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: Socialization. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(v) | The annual assessment dated 11/08/19 for individual #2 did not contain the individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | 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. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(e)(13)(vi) | The assessment dated 11/08/19 for Individual #2 did not include 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: Community-integration. | Program Specialist will receive remediation training on assessment requirements provided by CEO and additional organizational program specialists. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.36(a) | There was no documentation in the record that staff #1 received orientation before working with individuals.. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Program Specialist will maintain a spreadsheet for all staff orientation and training requirements. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Ongoing program specialist training and oversight will continue by the CEO. Principal and CEO will have monthly meetings to discuss staffing needs and requirements. Program Specialist will continue to monitor and CEO will oversee that no staff will work with individuals without required training and documentation. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |
| 2380.181(f) | An initial assessment for Individual #1 was not completed and sent to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Program Specialist will maintain a spreadsheet for all individual assessments which will include all required dates for creation and submissions. We recently went through a staffing change on July 1 where our previous program specialist was promoted to CEO and a new staff was hired to replace. Continued program specialist training and oversight will continue by the CEO. Principal and CEO will have monthly meetings to discuss current trends and all upcoming requirements. Program Specialist will continue to monitor and CEO will oversee. Program Specialist will assure all future compliance. |
01/31/2020
| Implemented |