| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(a) | Individual #1's assessment was completed on 3/13/2019 and then again on 11/17/2020. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual # 1 had an initial assessment on 3/13/2019. The annual assessment was completed on 11/17/2020. According to regulation 181(a) [Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.] The program specialist received conflicting training from the predecessor. The program specialist was taught to complete the annual assessment a month prior to the ISP meeting rather than annually. To correct this deficiency, the program specialist has been retrained and job description updated on 4/23/2021. |
04/23/2021
| Implemented |
| 6400.32(d) | The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. On 4/22/2021 at 11:52AM, Program Manager #1 was standing next to Individual #1 without a mask. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals. | An individual shall be treated with dignity and respect. | Family Services United (FSU) has developed the mission statement and values around this regulation and protects the fundamentals of individual rights. This agency was under the impression that ODP followed the Center for Disease Control (CDC) guidelines that states fully vaccinated people can gather indoors with other fully vaccinated people without a mask or social distancing and with other unvaccinated people from one other household. Both the individual #1 and the program manager #1 are vaccinated. ODP requires that staff continue to wear a mask that covers the mouth and nose while providing care. To correct this violation Family Services United conducted a COVID-19 Update training for direct support professionals, individuals, and program manager on 4/23/2021 and 4/28/2021. All attendees signed a COVID-19 consent form. The staff were instructed that despite the CDC recommendations, ODP requires a mask indoors [covering the nose and mouth be worn during the entirety of service provision and not doing so is undignified and disrespectful in that it creates a risk for transmitting the COVID-19 virus.] |
04/28/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained her individual rights on 3/13/2019 and then again on 4/10/2020.
Individual #1 was informed and explained individual rights on 4/10/2020. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the individual's bedroom door; 6400.32s, to have a key, access card, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.[Repeated violation 3/4/2020] | 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. | Family Services United (FSU) recognizes the importance of regulation 6400.34(a) ¿ 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. As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on admission (3/13/2019) and on 4/10/2020. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of the signature page only and not the resident rights for sample individuals via SharePoint. |
02/24/2021
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment, completed 11/17/2020 to the individual plan team members for an individual plan meeting on 12/7/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Family Services United (FSU) will ensure that assessments are submitted within the specified timeframe per regulations to the entire team. The program specialist is responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. FSU program specialist will discuss with team that ISP meetings will be scheduled at least 30 days after the anniversary dates. Residential director will oversee the entire process to ensure compliance is met. The assessment 30-day window will be placed on the residential director and program specialist calendar as a reminder. The residential director conducted a training refresher with program specialist on April 23,2021. Immediately, the residential director, or designee, shall train all staff responsible for completing any portion of the individual assessment, coordinating the completion of any portion of the assessment, or ensuring the completion of the individual assessment on the required components of an individual assessment, including required content and timelines, as indicated by 6400.181(a)-(f). |
04/23/2021
| Implemented |