| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certificate of compliance has an expiration date of 12/5/15; the self-assessment was completed on 9/28/15. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The CEO reviewed regulation 6400.15(a) in regards to self-assessments. Valley Advantages will monitor time frames in which the regulation must be completed, assuring for 2016 all self assessments will be completed between 6/5/2016-9/5/2016 [Immediately, CEO will develop and implement a system to alert as to when the self-assessment is due to be completed. CEO will monitor the alert system and review self-assessment to ensure timely completion. (AS 4/8/16)] |
01/30/2016
| Implemented |
| 6400.44(b)(1) | Individual #1's assessment, dated 6/19/15, was not completed by the Program Specialist. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | Valley Advantages in now aware of regulation 6400.44(b)(1) in regards to the Program Specialist completed the assessment. Regulation 6400.44(b)(1) was added to the Program Specialist Job Duties. See attachment 0001-D. The CEO will conduct random audits of the Program Specialist File to assure compliance with all 6400 Regulations.[Individual #1's assessment was signed as completed by the Program Specialist. Immediately and continuing at least quarterly, CEO will review all individuals' current assessments to ensure the completion by the program specialist. Documentation of reviews shall be kept. (AS 3/16/16)] |
01/30/2016
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 6/19/15, did not include functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Program Specialist reviewed regulation 6400.181 pertaining to individual assessments. 6400.181 (g) was added to the Job Description for the Program Specialist. The CEO will conduct random audits of the Program Department to assure compliance in all 6400 regulations. [Individual #1's assessment was updated to include documentation of the individual's disability, including functional and medical limitations. Immediately, the program specialist will review all individual's current assessment to ensure all required information is present including documentation of the individual's disability, including functional and medical limitations and will assess each individual in the missing areas. After the program specialist completes the next 5 full assessments the CEO will review the 5 assessments to ensure all required information is present including documentation of the individual's disability, including functional and medical limitations and will continue at least quarterly to review a 25% sample of individual assessments to ensure all required information is present including documentation of the individual's disability, including functional and medical limitations. Documentation of reviews shall be kept. (AS 4/8/16)] |
01/30/2016
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 6/19/15, did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist reviewed regulation 6400.181 pertaining to individual assessments. 6400.181 (d) was added to the Job Description for the Program Specialist assuring recommendations for specific areas of training, programming and services are added in the future to all individual assessments. The CEO will conduct random audits of the Program Department to assure compliance in all 6400 regulations.[Individual #1's assessment was updated to include areas to training, programming and services. Immediately, the program specialist will review all individual's current assessment to ensure all required information is present including recommendations for specific areas of training, programming and services and will assess each individual in the missing areas. After the program specialist completes the next 5 full assessments the CEO will review the 5 assessments to ensure all required information is present including recommendations for specific areas of training, programming and services and will continue at least quarterly to review a 25% sample of individual assessments to ensure all required information is present including recommendations for specific areas of training, programming and services. Documentation of reviews shall be kept. (AS 4/8/16)] |
01/30/2016
| Implemented |
| 6400.186(e) | The program specialist did not notify the plan team members for Individual #1 of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Valley Advantage program Specialist sent the notification to decline the ISp Review as defined in 6400.186(e) to individual #1 team. Regulation 6400.186(e) was added to the Program Specialist Job Duties. CEO will conduct quarterly audits to assure compliance with all regulations [On 3/21/16, Individual #1's team was notified of the option to decline the ISP review documentation. Immediately the program specialist will review all individuals' records including ISPs, invitation letter and other documentation to ensure all plan team members are notified of the option to decline ISP reviews documentation of the notifications shall be kept. At least quarterly, CEO will conducts checks of all individual records to ensure the plan team members for all Individuals are notified of the option to decline the ISP reviews. Documentation of the record reviews shall be kept. (AS 4/8/16)] |
01/30/2016
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include any identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Valley Advantages reviewed all individuals records and made necessary corrections. to assure compliance with regulation 6400.213(1)(I). Corrected records will become the template to assure continued compliance. CEO will conduct quarterly audits to assure compliance with all 6400 regulations. [Individual #1's record was updated to include "N/A." Immediately, CEO will review all individuals' records to ensure identify marks for all individuals are accurately included in the record and updated. At least quarterly audits of the records will be conducted by the CEO to ensure all personal information including identify marks is accurately included in all individuals' records. (AS 4/8/16)] |
01/21/2016
| Implemented |