| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(13) | The section pertaining to allergies on Individual #1's physical form was left blank.((repeat violation 3/6/18)) | The physical examination shall include: Allergies or contraindicated medications. | QLHS designated person will make sure the physician fills in all required areas on physical per ODP regulations before leaving the physician office. Administrative Staff will check over physical form before filing it . QLHS will train designated staff in proper procedures of clients physical forms |
11/30/2018
| Implemented |
| 6400.142(g) | Individual #1's hygiene plan was not updated annually. It was completed 04-17-17, then not since. | A dental hygiene plan shall be rewritten at least annually. | QLHS will train designated person to make sure the ODP required annual forms (Dental Hygiene ) are completed and filed in there charts in a timely manor designated person will update Tabula Pro
((QLHS will contact the dentist to obtain the missing information -12/3/18)) |
11/30/2018
| Not Implemented |
| 6400.181(d) | The signature on Individual #1's assessment is a photocopy and not dated. | The program specialist shall sign and date the assessment. | QLHS has created a new assessment to address all areas of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed (dated) to its entirety on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(1) | The strengths, needs, and preferences on Individual #1's assessment were from 2016.((repeat violation 3/6/18)) | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | QLHS has created a new assessment to address the strengths and needs of the residents. QLHS will train all designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(2) | The likes, dislikes, and interests on Individual #1's assessment were from 2016.((repeat violation 3/6/18)) | The assessment must include the following information: The likes, dislikes and interest of the individual. | QLHS has created a new assessment to address the interests of the residents. QLHS will train Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(3)(i) | It is unknown what the individual's current level of performance and progress is in the area of acquisition of functional skills. This is due to the fact that the information within the assessment is dated as being completed in April of 2016.((repeat violation 3/6/18)) | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | QLHS has created a new assessment to state the resident current level of performance and progress in functional Skills. QLHS will train all designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(3)(ii) | It is unknown what the individual's current level of performance and progress is in the area of communication. This is due to the fact that the information within the assessment is dated as being completed in April of 2016. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | QLHS has created a new assessment to address the current level of performance and progress of the residents. QLHS will train Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(3)(iii) | It is unknown what the individual's current level of performance and progress is in the area of personal adjustment. This is due to the fact that the information within the assessment is dated as being completed in April of 2016. | The individual's current level of performance and progress in the following areas: Personal adjustment. | QLHS has created a new assessment to address the current level of performance and progress in the area of personal adjustment
of the resident and documented properly . QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(3)(iv) | It is unknown what the individual's current level of performance and progress is in the area of personal needs with or without assistance from others. This is due to the fact that the information within the assessment is dated as being completed in April of 2016.((repeat violation 3/6/18)) | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | QLHS has created a new assessment to address the personal needs with or without assistance of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(9) | Individual #1's disability was not documented anywhere in his assessment.((repeat violation 3/6/18)) | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | QLHS has created new assessment forms that includes all required information. QLHS has complete a new assessment on individual #1 to ensure individual health and safety are met. the program specialist will be retrained on regulation 181(9) to ensure that the assessments are done on a timely manor. QLHS has programmed tabular pro to send reminders to the designated person and the program specialist. |
11/30/2018
| Not Implemented |
| 6400.181(e)(10) | There was no lifetime medical history documented within Individual #1's assessment ((repeat violation 3/6/18)) | The assessment must include the following information: A lifetime medical history. | QLHS has completed the life time medical History for the residents and the team leads has been trained on how to complete them and when to complete them. |
11/30/2018
| Implemented |
| 6400.181(e)(13)(ii) | No progress over the last 365 days or current level was shown in the area of motor and communication skills on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16.((repeat violation 3/6/18)) | 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. | QLHS has created a new assessment to address motor and communication skills of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(iii) | No progress over the last 365 days or current level was shown in the area of activities of residential living on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16.((repeat violation 3/6/18)) | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | QLHS has created a new assessment to address the residents area of activities and residential living. QLHS will train Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(iv) | No progress over the last 365 days or current level was shown in the area of personal adjustment on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | 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. | QLHS has created a new assessment to address the area of Personal adjustment of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(v) | No progress over the last 365 days or current level was shown in the area of socialization on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | 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. | QLHS has created a new assessment to address the area of socialization of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(vi) | No progress over the last 365 days or current level was shown in the area of recreation on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | 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. | QLHS has created a new assessment to address the area of recreation of the residents. QLHS will train all the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(vii) | No progress over the last 365 days or current level was shown in the area of financial independence on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| QLHS program specialist created new assessment form that the program specialist/ designated person will be trained on how to complete the assessment. individual #3 assessment will be redone. QLHS will use tabular pro to remind the program specialist and designated person when assessment are due. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(viii) | No progress over the last 365 days or current level was shown in the area of managing personal property on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | QLHS has created a new assessment to address the areas of managing personal property of the residents. QLHS will train the Program Specialist and designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(e)(13)(ix) | No progress over the last 365 days or current level was shown in the area of community integration on Individual #1's assessment. Although it states 2016, 2017, 2018···all of the information in the assessment was photocopied, most of it still dated 04/16/16. ((repeat violation 3/6/18)) | 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. | QLHS has created a new assessment to address the area of community integration of the residents. QLHS will train the Program Specialist and the designated person how to fill out the assessment. QLHS is updating all assessment on the new assessment forms. QLHS will use Tabular pro system to remind the designated person when the assessment are due insure that the assessments are completed on a timely manner. |
11/30/2018
| Not Implemented |
| 6400.181(f) | There assessment for Individual #1's was not sent to the SC and team at least thirty days prior to the ISP meeting. ((repeat violation 3/6/18)) | (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).
| QLHS Program Specialist /has been retrained on 6400.181(f) showing when the assessment should be sent to SC/ team Administrative staff is following up to make sure the assessment was sent to the SC and documentation will be kept |
11/30/2018
| Implemented |
| 6400.186(a) | The were only two quarterlies in Individual #1's file. The most recent does not have the date span on it for which three months were reviewed. ((repeat violation 3/6/18)) | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | QLHS has updated tabular Pro to update designated person when quarterlies are due. QLHS has created a new quarterly form to use every Quarter
((Program Specialist or designee will complete monthly chart reviews to ensure ISP Reviews are completed within the regulated timeframe -CH 12/3/18)) |
10/10/2018
| Not Implemented |
| 6400.186(b) | For the two quarterlies that were in Individual #1's file, only one was signed, but neither was dated. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | QLHS will retrain Program Specialist and designated person the proper procedure to filling out the Quarterlies correctly and to its entirety Administrative staff will read over finished Quarterly to make sure its completely filled out |
11/30/2018
| Not Implemented |
| 6400.186(c)(2) | The ISP Reviews for Individual #1 did not review the entire ISP. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | QLHS program specialist and all designated person has been retrained on what the process is for reviewing the individual ISP. QLHS has developed a new ISP Review format to ensure all regulated areas are covered. |
11/30/2018
| Implemented |