Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.111(c)(7) | Individual #1's current, 8/27/21 physical examination record did not include their health maintenance needs. The field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Contact was made with Individual #1's parent explaining that while the physical form they submitted was from another licensed provider, there are different regulatory requirements and we must have our agency physical form completed and all listed areas must be filled in. Our agency physical form was sent to the individual's physician, who sent it back with all areas completed. (See Att. #1). Program Specialists received training on the requirement that all physical examinations for individuals must contain the required information listed in 2380.111. (See Att. #2). All current program files will be reviewed and physicals inspected to ensure that all sections are completed on each physical. If it is found that the physical does not contain needed information, the individual and/or their parent/guardian will be contacted and given a copy of Able-Services' physical form and asked to assist Able-Services in contacting their physician to have all sections of the physical form completed. |
02/25/2022
| Implemented |
2380.111(c)(9) | Individual #1's current, 8/27/21 physical examination record did not include their allergies and contraindicated medications. The field was left blank. According to their record, they have allergies to Pravastatin and Ice Melt. | The physical examination shall include: Allergies or contraindicated medication. | Contact was made with Individual #1's parent explaining that while the physical form they submitted was from another licensed provider, there are different regulatory requirements and we must have our agency physical form completed and all listed areas must be filled in. Our agency physical form was sent to the individual's physician, who sent it back with all areas completed. (See Att. #1). Program Specialists received training on the requirement that all physical examinations for individuals must contain the required information listed in 2380.111. (See Att. #2). All current program files will be reviewed and physicals inspected to ensure that all sections are completed on each physical. If it is found that the physical does not contain needed information, the individual and/or their parent/guardian will be contacted and given a copy of Able-Services' physical form and asked to assist Able-Services in contacting their physician to have all sections of the physical form completed. |
02/25/2022
| Implemented |
2380.111(c)(10) | Individual #1's current, 8/27/21 physical examination record did not include information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Contact was made with Individual #1's parent explaining that while the physical form they submitted was from another licensed provider, there are different regulatory requirements and we must have our agency physical form completed and all listed areas must be filled in. Our agency physical form was sent to the individual's physician, who sent it back with all areas completed. (See Att. #1). Program Specialists received training on the requirement that all physical examinations for individuals must contain the required information listed in 2380.111. (See Att. #2). All current program files will be reviewed and physicals inspected to ensure that all sections are completed on each physical. If it is found that the physical does not contain needed information, the individual and/or their parent/guardian will be contacted and given a copy of Able-Services' physical form and asked to assist Able-Services in contacting their physician to have all sections of the physical form completed. |
02/25/2022
| Implemented |
2380.111(c)(11) | Individual #1's current, 8/27/21 physical examination record did not include special dietary needs. The field was left blank. | The physical examination shall include: Special instructions for an individual's diet. | Contact was made with Individual #1's parent explaining that while the physical form they submitted was from another licensed provider, there are different regulatory requirements and we must have our agency physical form completed and all listed areas must be filled in. Our agency physical form was sent to the individual's physician, who sent it back with all areas completed. (See Att. #1). Program Specialists received training on the requirement that all physical examinations for individuals must contain the required information listed in 2380.111. (See Att. #2). All current program files will be reviewed and physicals inspected to ensure that all sections are completed on each physical. If it is found that the physical does not contain needed information, the individual and/or their parent/guardian will be contacted and given a copy of Able-Services' physical form and asked to assist Able-Services in contacting their physician to have all sections of the physical form completed. |
02/25/2022
| Implemented |
2380.115(1) | The written emergency medical plan didn't include the specific hospital or source of health care to be used in the event of a medical emergency at the facility. | The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Able-Services' Emergency Medical Plan was updated on 2/24/22 to more clearly specify the regulation requirements, namely the specific hospital or source of health care to be used in the event of a medical emergency at the facility. (See Att. #3) Program staff received training on this updated plan. (See Att. #4) |
03/02/2022
| Implemented |
2380.173(1)(ii) | Individual #1's record didn't include identifying marks. Their record stated, "wears glasses and hearing aids," that are items that can be removed from oneself.
Individual #3's record didn't include identifying marks. Their record stated, "wears glasses." | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The cover sheets for Individual #1 and Individual #3 have been updated to include identifying marks and remove the listing of items, such as glasses and hearing aids, that can be removed from oneself. (See Att. # 5 and Att. #6). Program Specialists have been retrained in what constitutes an identifying mark, that this does not include items that can be removed from oneself, and their responsibility for ensuring this information within the individual file is complete and accurate. (See Att. #2) Cover sheets for current participants will be reviewed to ensure that appropriate identifying marks are included for all individuals and do not include removable items. Any needed corrections will be made upon discovery. |
02/25/2022
| Implemented |
2380.181(a) | Individual #2 entered the program on 4/6/2021 and did not have an initial assessment completed until 6/16/2021. | 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. | This correction is unable to be made, since the required date is already passed. |
02/23/2022
| Implemented |
2380.181(e)(2) | Individual #4's current, 8/6/21 assessment doesn't include dislikes. The field for this states, "n/a" for not applicable. This regulation is applicable to all individuals' assessments and the facility is required to assessed individuals' dislikes. According to other record information maintained at the facility, Individual #4 does not like certain crowds and/or environments that are very stimulating and also may cause seizures, exhibits various behaviors to undesired words or items, and does not like words or phrases that start with "st", "bad", "off", or "alone". | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | An addendum to Individual #4's Assessment was completed on 2/24/22 to include information on his dislikes and this addendum was sent was sent to all the members of Individual #4's ISP Team. (See Att. #8) Program Specialists received additional assessments and how this regulation is applicable to all individual assessments and should not be marked as "n/a". (See Att. #2). |
02/24/2022
| Implemented |
2380.21(u) | There are no records maintained that the facility informed and explained individual rights and the process to report a rights violation, defined in 2380.21(a)-(t), with Individuals #1-#4 initially upon admission and annually thereafter. Staff person #1 confirmed on 2/17/2022 that staff from the facility do not inform and explain the individuals' rights and the process to report a rights violation to the individuals, but the facility provides a copy of the individuals' right to them via mail. Additionally, a review of 2380.21(d) and (g) was not included in the mailed individual rights document, or explained to any individuals by the facility. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | The Individual Rights Policy has been updated to include all individual rights, including those listed in 2380.21(d) and (g). The individuals selected for monitoring (#1, 2, 3, 4) have received training on their rights and they (and applicable guardians) have signed the policy acknowledging receipt of this information. (See Att. #9) All current participants and guardians will receive training on their rights by March 11, 2022 and documentation of receipt of this information will be kept in the individuals' files. The Program Handbook, which is reviewed yearly and given to all participants and contains pertinent policies, procedures, and programmatic information, has been updated to include a complete list of all the individual rights in 2380.21. (See Att. #10) |
02/25/2022
| Implemented |
2380.125(f) | According to Individual #1's individual plan, "{Individual #1 may display symptoms related to their anxiety. Should {Individual #1} begin to display these symptoms, staff will remain calm and attempt to redirect {the individual} to a preferred activity, such as doing something active, moving to a quieter area to allow some time alone to calm down slowly, or the opportunity to talk when {the individual} feels they are ready." However, the individual's plan does not include the specific symptoms of anxiety they experience, that trigger the need for staff to implement the plan and assist the individual through their specific symptoms of anxiety. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Staff talked to Individual #1 and her mother about what specific symptoms of anxiety look like for her that may trigger the need for staff to implement her SEEN plan while she is receiving services. Individual #1's SEEN Plan was updated with this information (See Att. #11) and a request was sent to the Supports Coordinator to update this plan in the individual's ISP. (See Att. #12). Staff members were retrained on Individual #1's updated SEEN Plan with the additional symptoms of anxiety. (See Att. #13). This information was also updated on Individual #1's cover sheet, which is accessible to staff at all times electronically. (See Att. #5) Program Specialists were trained on the requirement that specific symptoms of an individual's psychiatric illness should be included within their SEEN Plan. (See Att. #2). The SEEN Plans of current program participants will be reviewed to ensure that they contain symptom information. If any are found to not have specific symptoms included, the Program Specialist will ensure these are added to the plan, request the appropriate update(s) to the individual's ISP, and train staff in the updated plan. |
02/23/2022
| Implemented |
2380.181(f) | Individual #1's assessment was not sent to their other prevocational facility team member.
Individual #3 had their annual individual support plan (isp) meeting held on 10/26/2021, but their assessment was not sent to team members until 11/18/2021. Additionally, a team member from another agency who was present at the annual isp meeting, did not receive a copy of the individual's assessment.
Individual #4's 8/6/21 assessment was not sent to their prevocational team member prior to their 9/23/21 annual isp 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. | The most recent annual assessments for Individual #1, Individual #3, and Individual #4 were sent to the ISP Team members from other service provision agencies that did not receive their most recent annual assessment. (See Att. # 14, Att. #15, and Att. #16). Program Specialists were retrained on the requirement that assessments must be provided to all individual plan team members at least 30 calendar days prior to the individual plan meeting and that this includes other service providers. (See Att. #2) Current assessments will be reviewed to ensure that they were sent out to all ISP Team Members listed in the ISP and/or that attended the Annual ISP Meeting. If it is found that any team members did not receive the most recent assessment, contact information will be obtained and the assessment will be sent to them upon discovery. Program Specialists reviewed the assessment dates of individuals on their caseloads and moved up the dates of any assessments that would be due in the immediate time period surrounding an individual's annual ISP meeting to ensure that the assessment is always completed and sent out to the ISP Team 30 days prior to the scheduled annual ISP meeting. |
02/24/2022
| Implemented |
2380.186 | Individual #4's individual plan states that the individual is diagnoses with non-convulsive seizure disorder, has a seizure every 4-6 months, the individual will stare, swallow, and make throat clearing noises, and that their seizure frequency and symptoms are tracked daily by the facility and family. Staff person #1 reported on 2/17/22 they were not aware this was located in the individual's individual plan and the facility was not monitoring or tracking any seizure activity or symptoms described in the plan for Individual #4. | The facility shall implement the individual plan, including revisions. | The intention of the ISP team, as discussed during Individual #4's intake and at his annual ISP reviews, is that if Individual #4 has a seizure during CPS services, his seizure and the symptoms he experienced will be documented in his electronic health record and shared with the individual's mother. Individual #4's ISP has been updated to change the frequency of this health promotion activity to as needed. (See Att. #17) Though this information is included in the individual's ISP, which staff are trained on annually, to ensure staff are clear on what they may observe if Individual #4 has a seizure and their reporting requirements, this information was included on Individual #4's cover sheet, which staff are able to access electronically at any time. (See Att. #18) In addition, staff were retrained on this expectation. (See Att. #19) |
03/02/2022
| Implemented |