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The Program Coordinator will train the QIDP on the importance of providing a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. This will include, but not be limited to the importance of implementing and practicing programs which are consistent with the individual's plans on a continuous basis to promote independence and growth. This will be done by ensuring new training plans are promptly implemented as soon as the previous plan in that domain is achieved or discontinued. The training will be complete by September 15, 2024 and signed and dated by the Program Director to ensure completion. Training documents will be filed by the Human Resources Department. Training will be filed in the employee's personnel record.

On August 8, 2024 it was confirmed that Individuals #1, #2, and #3 have current goals in each of the four skill areas. The QIDP will review the records of individuals #4, #5, and #6 to assure they each have a current goal in all four skill areas. This will be done by September 22, 2024. The QIDP will make all revisions or extensions needed, including baselining and developing new goals as needed. Documentation of the review, and revisions needed will be emailed to the Program Coordinator, who will monitor for completion. The Program Coordinator will document her review by responding to the email, and maintain the communication chain in a Plan of Correction folder.

All individual program plans in the home will be reviewed by the QIDP at least one time every two weeks for three months to ensure each client receives continuous active treatment consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. The review will also ensure new training plans are promptly implemented as soon as the previous plan in that domain is achieved or discontinued. Program plans will be revised as necessary. The QIDP, or designee, will document her review by signing and dating the program plan.

To ensure compliance, all individual program plans in the home will be reviewed by the Program Coordinator one time per month for at least three months, starting September 22, 2024, to ensure goal programs are implemented on a continuous basis to promote independence and growth. The review will also ensure new training plans are promptly implemented as soon as the previous plan in that domain is achieved or discontinued. Feedback will be given to the QIDP as needed via documentation on the program plan. The review will be documented by signing and dating the program plan. Within one week, the Program Coordinator will meet with the QIDP to review all program plans and ensure all feedback is implemented. The Program Coordinator will document her review by signing and dating the program plan.

Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.

The Director of Nursing will train the Health Services Coordinator on the significance of nursing services including, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need. This includes specifying the quarterly physical examination is due every 90 days, the date each assessment is due by, and the importance of the Health Services Coordinator completing quarterly physical examinations due that month. Training will also focus on the importance of conveying due nursing assessments to covering nurses when the primary nurse is out of the office. Training will be completed by September 15, 2024 and signed by the Program Director to confirm completion. Training will be filed in the employee's personnel record.

The Health Services Coordinator completed a review of health status for Individual's #1, #2, #3, and all individuals on July 8, 2028. The Director of Nursing will review the assessments to assure completion and will scan and email them to the Program Director to be maintained in a Plan of Correction folder.

The Health Services Coordinator with work with the Medical Administrative Support person to update the Medical Appointment Calendar to list the upcoming dates quarterly nursing assessments will be due in, for the remainder of 2024 and 2025. Upon completion the Medical Administrative Support will email the calendars to the Director of Nursing, who will assure completion. The Director of Nursing will document her review by responding to the email and copying the Program Director, who will save the email in a Plan of Correction folder. This will be done by September 22, 2024. Having the quarterly nursing assessments on the medical appointment calendar will prompt a covering nurse to complete them, as they will be considered a scheduled appointment.

The Director of Nursing will monitor the documentation system monthly by the 15th of each month for the next six months to ensure that quarterly examinations are completed. If there are no gaps in quarterly examinations after the six months, the process will remain in place and not fade, however oversight by the Director of Nursing will. If quarterly physical examinations are not done within the quarter creating a gap, retraining will be done by the Director of Nursing with the Health Services Coordinator within 24 business hours and the physical examination not completed will be done immediately. The corrective actions proposed in this plan of correction will then continue.

Failure to follow the information outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.