| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Individual #4 was instructed in fire safety training on 05/06/19. After a closure of the Vocational Facility in March 2020 due to COVID, Individual #4 returned to Vocational Facility on 07/27/20. The written record of fire safety training on 07/27/20 did not include Individual #4's signature; therefore, compliance could not be measured. | Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept. | A Fire Safety documentation form has been developed to track all fire safety trainings, dates and signatures. This form has been added to the Monthly Program Specialist checklist form which is completed monthly. In addition to the Fire Safety documentation form, the PS checklist form will be submitted to the licensor for review. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 10% sample of individual fire safety documentation to ensure all individual are instructed in fire safety, timely and documentation is maintained to ensure compliance can be measured. (DPOC by AES,HSLS on 1/5/21)] |
12/16/2020
| Implemented |
| 2390.101 | Individual #1's physical examination, dated 04/19/19, Individual #2's physical examination, dated 10/09/20 and Individual #3's physical examination, dated 03/11/20 did not address communicable diseases. This section was left blank; therefore, compliance could not be measured. | Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician. | The physical exam form has been revised to enhance and highlight the Free From Communicable Disease section. In addition, the Program Specialists developed a cover letter (attachment being submitted to licensor) to accompany each exam sheet. Also, the day program will not permit attendance if the physical is missing or incomplete. This will be reviewed with all participants upon re-entry to the program once reopened via the day program handbook. [Upon completion and submission to the facility, the CEO or designee shall audit all individuals' current physical examinations to ensure communicable disease is addressed. In addition, the CEO or designee shall educate staff, clients and volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician. Documentation shall be kept. (DPOC by AES,HSLS on 1/5/21)] |
12/15/2020
| Implemented |
| 2390.21(u) | Individual #1 was informed and explained individual rights on 10/12/20. The rights document did not include the following rights: 2390.21(e)-(g) relating to a court-appointed guardian; 2390(l) relating to the right to make choices and accept risks; and 2390(n)-(o) relating to the person's possessions. | The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter. | The individual rights have all been updated to reflect the 6100 regulations, specifically including court appointed guardians, the right to make choices and accept risks and rights regarding personal possessions. The rights will be reviewed with all participants upon reentry into the program. A copy of the revised rights will be submitted to the licensor. [Upon reopening of the facility (closed due to COVID-19) and readmission of the individuals, the CEO or designee shall audit the individuals' updated rights documentation to ensure all individual are informed and explained the client rights and the process to report a rights violation to the individual. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/5/2021)] |
12/15/2020
| Implemented |
| 2390.151(f) | The program specialist provided Individual #2's assessment, dated 6/10/19 to the plan team members on 03/02/2020 for an ISP meeting on 03/20/2020. The program specialist provided Individual #5's assessment, dated 3/24/2020 to the plan team members on 04/15/2020 for an ISP meeting on 04/23/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting. | All Program Specialists were trained in 2390.151 Assessment (training record will be submitted) and a checklist was developed for monthly Program Specialist review. The checklist will be due to the IDD Quality manager on the last day of the month. The IDD Quality Manager will audit all IDD charts on a quarterly basis. |
12/18/2020
| Implemented |