| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | Individual #1's physical examination, completed 7/16/19 did not include vision and hearing screening. This section was left blank. Individual #2's physical examination, completed 7/10/19 did not include vision and hearing screening. This section was left blank. Individual #4's physical examination, completed 6/29/19 did not include vision and hearing screening.This section was left blank. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | For the survey sample the program specialist has been in communication with the teams to obtain all of the hearing and vision information required by regulations. For all others, the program specialist has reviewed the physicals on file and confirmed that all current physical examinations on hand are completed by the physician with all necessary information. For those who have not yet provided the required information, a letter has been sent requesting the needed information. If the information is not provided by 11/15/19, the participant will be subject to suspension until the information is provided. Ongoing before filing, the program specialist will ensure the physical forms are completed with all necessary information and if not the team will be contacted and communication will be maintained. [Documentation of all audits of individuals' physical examinations by the program specialist shall be kept. DPOC by AES,HSLS on 10/28/19)] |
11/15/2019
| Implemented |
| 2380.111(c)(7) | Individual #1's physical examination, completed 7/16/19 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank. Individual #2's physical examination, completed 7/10/19 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section 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. | For the survey sample the program specialist has been in communication with the teams to obtain all of the health maintenance needs, medication regimen, and blood work information required by regulations. For all others, the program specialist has reviewed the physicals on file and confirmed that all current physical examinations on hand are completed by the physician with all necessary information. For those who have not yet provided the required information, a letter has been sent requesting the needed information. If the information is not provided by 11/15/19, the participant will be subject to suspension until the information is provided. Ongoing before filing, the program specialist will ensure the physical forms are completed with all necessary information and if not the team will be contacted and communication will be maintained. [Documentation of all audits of individuals' physical examinations by the program specialist shall be kept. DPOC by AES,HSLS on 10/28/19)] |
11/15/2019
| Implemented |
| 2380.111(c)(10) | Individual #3's physical examination, completed 5/15/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #4's physical examination, completed 6/29/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | For the survey sample the program specialist has been in communication with the teams to obtain all of the information pertinent to diagnosis and treatment in case of an emergency as required by regulations. For all others, the program specialist has reviewed the physicals on file and confirmed that all current physical examinations on hand are completed by the physician with all necessary information. For those who have not yet provided the required information, a letter has been sent requesting the needed information. If the information is not provided by 11/15/19, the participant will be subject to suspension until the information is provided. Ongoing before filing, the program specialist will ensure the physical forms are completed with all necessary information and if not the team will be contacted and communication will be maintained.[Documentation of all audits of individuals' physical examinations by the program specialist shall be kept. DPOC by AES,HSLS on 10/28/19)] |
11/15/2019
| Implemented |
| 2380.173(5) | Individual #1's record did not include a signature page for the annual ISP meeting held on 5/23/19. Individual #2's record did not include an invitation for the annual ISP meeting held on 4/17/19 . | Individual plan documents as required by this chapter. | For the survey sample and all others, the program specialist has confirmed an ISP signature page is on file. Ongoing, the program specialist will make a copy of the signature page at the end of the Annual ISP meeting. The signature page will be maintained in the individuals¿ charts. [At least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure all required information is included in all individuals' records. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/28/19)] |
10/24/2019
| Implemented |
| 2380.181(f) | The program specialist did not provide Individual #2's assessment, completed 10/19/18 to individual plan team members for the individual plan meeting on 4/17/19. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | For the survey sample and all others, the program specialist confirmed that all assessments are completed and have a letter indicating distribution to the team. Ongoing, per regulations, at least 30 day prior to the annual ISP the assessment will be distributed to the team and a letter will be maintained on file to show distribution. The Director will review tracker monthly and send out an email to PS with due dates of upcoming assessments. A calendar reminder has been added to the Director¿s calendar to do so on the first Wednesday of each month. Documentation of the aforementioned audits by the Director shall be kept. |
10/24/2019
| Implemented |
| 2380.182(c) | Individual #2's assessment, completed 10/19/2018 assessed Individual #2 independent for evacuation. Individual #2's ISP, updated 6/18/19 reflects Individual #2 needs prompting for safe evacuation. Individual #3's assessment completed 1/11/19 assessed Individual #3 as independent with heat sources and water. Individual #3's ISP updated 6/7/19 reflects Individual #3 require monitoring when using the stove, needs to have water temperature checked for showering and needs "visual supervision when in the pool." Individual #4's assessment completed 8/30/19 assessed Individual #4 as independent with water skills and "able to understand water safety and will go into a pool or lake as long as he can touch the bottom. He is not able to swim." Individual #4's ISP updated 7/22/19 reflects Individual #4 is unable to regulate water and does not address the ability to swim. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | For the survey sample and all others, the program specialist is reviewing all assessments and ensuring that all individual¿s needs are addressed in their current assessment and the assessment has been distributed to all team members. This review will be completed by 10/31/2019. The program specialist will then communicate with the appropriate party to ensure accurate information is documented in the ISP. After the initial request the program specialist will continue to monitor the ISP for the updated information and if not yet addressed will send a correspondence to the appropriate party to find out current status. The program specialist will keep documentation of all correspondence in the individual¿s chart. [At least quarterly for 1 year, the CEO or designee shall audit a 10% sample of individuals' assessments and IPs to ensure the current IP is based on the current assessment. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/28/19)] |
11/15/2019
| Implemented |