| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 had follow up dental appointment scheduled for 10/29/2020 there is no documentation that this appointment occurred. The agency states that her mother attended the appointment with her. Her mother who is Individual #1's legal guardian requested the agency not attend. The agency states that Individual #1 went home on 11/20/2020 and has not returned and that Individual #1's mother revoked all the agencies releases of information. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Individual #1's guardian was uncooperative in sharing information regarding medical care. Individual #1's mother has taken her home due to COVID and does not plan to have her return until COVID is done. Moving forward LVAS will make it clear to parents/guardians that medical must be shared in accordance with regulations. If there is any issue the SC will be notified and all attempts will be clearly documented. |
12/30/2020
| Implemented |
| 6400.181(e)(3)(iii) | This area was not in Individual #1's assessment dated 8/18/2020. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Previously the program specialists did not have a clear understanding of the 6400 regulations. Training was conducted with current program specialists on 1/14/2021 to clarify show growth and progress (or lack of) in all identified areas of the assessment. LVAS client services department has made revisions to the initial and annual assessments so necessary information is clearly defined. All adjustments to the assessment template will be made by 3/31/2021. All assessments will be reviewed by the assistant director of client services. (or equivalent) to ensure quality and compliance in 2021 and forward. |
03/31/2021
| Implemented |
| 6400.181(e)(4) | Need for Supervision: Individual #1's assessment dated 8/18/2020 states that their current unsupervised time allotted as n/a. ( Individual #1's ISP states they can be left alone for up to 4 hours if needed, however, she is never left alone overnight. Individual #1 can be left alone for up to 2 hours in the community, as long as she has access to her cell phone to update family.) | The assessment must include the following information: The individual's need for supervision.
| Previously the program specialists did not have a clear understanding of the 6400 regulations. Individual #1 had moved from home, the assessor did not request the SC update the plan to reflect the residential supervision levels. LVAS client services department has made revisions to the initial and annual assessments so necessary information is clearly defined. All adjustments to the assessment template will be made by 3/31/2021. All assessments will be reviewed by the assistant director of client services. (or equivalent) to ensure quality and compliance in 2021 and forward. |
03/31/2021
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment dated 8/18/2020 did not include their ability to use or avoid poisonous material. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Previously the program specialists did not have a clear understanding of the 6400 regulations. LVAS client services department has made revisions to the initial and annual assessments so necessary information is clearly defined. This includes check box for ability to safely use and avoid poisons. All adjustments to the assessment template will be made by 3/31/2021. All assessments will be reviewed by the assistant director of client services. (or equivalent) to ensure quality and compliance in 2021 and forward. |
03/31/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed of their rights on 8/10/2020. The Individual Rights have not been updated to reflect the new Chapter 6400 regulations. | The home 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 home and annually thereafter. | Client service team did not match the new regulations to the current documentation being given to individuals. Client Rights policy was revised and is being reviewed with all staff and individuals during January 2021. However individual #1 is still home with family due to concerns over COVID-19 . The new rights policy will be reviewed and signed upon return. Client Rights policy will be reviewed with all clients upon admission and annually there after. Quality Management will review updates from ODP regularly to ensure policy is updated to comply with current regulations. |
01/14/2021
| Implemented |
| 6400.169(d) | Staff #1 did not have a completed medication practicum. Staff #2 did not have a second observation of medication administration. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | 1 person was tracking all med admin paperwork with no checks and balances in place. practicums were completed for staff #1 & staff #2 by 12/15/2020. Medication training info will be placed in the Bamboo HR database once it is fully functioning so there are checks and balances |
01/11/2021
| Implemented |
| 6400.182(a) | 182A : Individuals plan shall be revised when an individual's needs change based upon a current assessment. Individual #1's assessment dated 8/18/2020 states that their current unsupervised time allotted as n/a, and Individual #1's ISP states they can be left alone for up to 4 hours if needed, however, she is never left alone overnight. Individual #1 can be left alone for up to 2 hours in the community, as long as she has access to her cell phone to update family. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | Previously the program specialists did not have a clear understanding of the 6400 regulations. Individual #1 had moved from home, the assessor did not request the SC update the plan to reflect the residential supervision levels. LVAS client services department has made revisions to the initial and annual assessments so necessary information is clearly defined. All adjustments to the assessment template will be made by 3/31/2021. All assessments will be reviewed by the assistant director of client services. (or equivalent) to ensure quality and compliance in 2021 and forward. |
03/31/2021
| Implemented |