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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #2, date of hire 4/1/2019, had a Pennsylvania criminal history record check requested on 6/24/19. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Direct Service Worker #2 had been working with Individual #1 for a few weeks prior to the new licensed residential company taking over on 4/1/2019. The previous company was to relay their former employee¿s Pennsylvania Criminal History Record Check. However, it was not received. Accordingly, the company will be sure to conduct their own background checks even with transitional individuals and employees to ensure background checks applications are submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. On July 25th, 2019, the House Manager and CEO reviewed regulation 6400.21 titled, ¿Criminal History Record Check.¿ The training was conducted by the owner and detailed the components stating, ¿An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employee of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person¿s date of hire.¿ Moreover, the CEO was instructed by the owner to have the prospective employee fill out and sign a background check release form that may be found on the company computer. The CEO will conduct the record check with the company card thru the https://epatch.state.pa.us webpage. The prospective employee¿s information will be entered and the CEO will be given a control number that the CEO shall reference to check the status of the record check. Furthermore, the CEO and House Manager are aware how crucial it is to review dates history record checks were completed to ensure they have not been completed more than 1 year prior to the person¿s date of hire. The CEO and House Manager also understand to be conscious of where an individual resides, in order to verify if an FBI criminal history check shall be submitted and ensure compliance. Additionally, both parties understand that if an FBI check is to be conducted.
Both parties also understand if the home serves primarily individuals who are 17 years of age or younger Child Clearances must be completed. However, this does not apply right now because the home only serves adults.
The House Manager and CEO have been trained to maintain and keep a copy of the final reports received from the State Police and the FBI, (if applicable). A copy of the final reports received are to be kept and maintained in the employee or prospective employee¿s file. Additionally, the Pennsylvania Criminal History Record Check is included on the Initial Employee Checklist. A checklist page was made to ensure required documents have been submitted & completed prior to a position being fulfilled. The hiring manager will review the checklist and ensure all documentation has been complete & submitted. The hiring manager must initial and date the checklist to confirm the physical exam has been completed & reviewed. Upon doing so, the owner will be contacted and conduct a review of the CEO/PS and/or DSW¿s file to confirm all documentation has been received. The owner will then initial and date the checklist to ensure all of the documentation has been reviewed in the CEO/Program Specialist¿s and/or Direct Service Worker¿s file. The CEO will review employee files quarterly to ensure all of these guidelines within the regulations are being met for the criminal background checks. The CEO and House Manager will be trained on this at least annually or on an ¿as needed¿ basis. |
07/25/2019
| Implemented |
| 6400.22(d)(1) | The home does not have an up-to-date financial and property record for Individual #1 that includes personal possessions and funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | On July 1st, 2019, the financial and property record log for Individual #1 that includes personal possessions and purchases was created. The financial and property record was not requested at the renewal inspection.
Additionally, receipts are kept in a booklet with the Financial Log Binder in the kitchen cabinet to the left of the fridge. During the week of July 1st, 2019, the House Manager, CEO and Direct Service Workers were trained on the financial log and the receipt booklet by the owner. The staff members were trained to start a new financial purchase log page for each month. The page must include the month and year. Next, when documenting purchases, the date, name of the participant, activity/item purchased, form of payment (i.e. cash, credit card, etc.), total money spent, the initials of one staff member on that shift and the participant¿s initials (if applicable) must be documented. Additionally, all receipts must be accounted for. During the week of August 21st, the staff members reviewed the regulation 6400.22 titled, ¿Individual Funds and Property,¿ which is where the company¿s Financial Policy was derived from. The policy states that nobody may prohibit the individual¿s right to manage his/her own finances and that individual funds and property shall be used for the individual¿s benefit. Additionally, the financial and property record log shall be up-to-date for each individual that includes personal possessions and funds received by or deposited with the home, as well as disbursements made to or for the individual.
Consequently, all staff was trained by August 20th, 2019 to be sure to include disbursements to the individual as well on the log. Personal possessions and funds received by or deposited with the home shall be included on the log. Additionally, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person must be accounted for on the financial and property record log. The home and staff members are aware that there may be no commingling of the individual¿s personal funds and that there may be no borrowing of the individual¿s personal funds by staff persons or by the home. Furthermore, the home¿s financial policy also states, ¿If the home assumes the responsibility of maintaining an individual¿s financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. For a withdrawal, when the individual is given the money directly, the record shall indicate that funds were given directly to the individual and lastly, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.
Moreover, the policy establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property.
The House Manager was trained to review the financial log monthly and make sure the financial purchase log is filled out accurately and completely. The House Manager reports all findings to the CEO to help ensure the best financial keeping practices. The CEO reviews the logs as well and helps recommend budgeting ideas to the Individual. The CEO/Program Specialist may make recommendations for ideas for entertainment/activities when it is within the Individual¿s budget as well. The CEO reports to the owner in regards to financial practices/ideas for entertainment and/or budgeting prior to consulting with the individual. Staff members will be trained on the financial policy and practices at least annually or on an ¿as needed¿ basis by the CEO and/or owner to ensure the Individual Funds and Property Regulations are known and being followed. |
08/20/2019
| Implemented |
| 6400.22(d)(2) | The home does not have an up-to-date financial and property record for Individual #1 that includes disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| On July 1st, 2019, the financial and property record log for Individual #1 that includes personal possessions and purchases was created. The financial and property record was not requested at the renewal inspection.
Additionally, receipts are kept in a booklet with the Financial Log Binder in the kitchen cabinet to the left of the fridge. During the week of July 1st, 2019, the House Manager, CEO and Direct Service Workers were trained on the financial log and the receipt booklet by the owner. The staff members were trained to start a new financial purchase log page for each month. The page must include the month and year. Next, when documenting purchases, the date, name of the participant, activity/item purchased, form of payment (i.e. cash, credit card, etc.), total money spent, the initials of one staff member on that shift and the participant¿s initials (if applicable) must be documented. Additionally, all receipts must be accounted for. During the week of August 21st, the staff members reviewed the regulation 6400.22 titled, ¿Individual Funds and Property,¿ which is where the company¿s Financial Policy was derived from. The policy states that nobody may prohibit the individual¿s right to manage his/her own finances and that individual funds and property shall be used for the individual¿s benefit. Additionally, the financial and property record log shall be up-to-date for each individual that includes personal possessions and funds received by or deposited with the home, as well as disbursements made to or for the individual.
Consequently, all staff was trained by August 20th, 2019 to be sure to include disbursements to the individual as well on the log. Additionally, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person must be accounted for on the financial and property record log. The home and staff members are aware that there may be no commingling of the individual¿s personal funds and that there may be no borrowing of the individual¿s personal funds by staff persons or by the home.Furthermore, the home¿s financial policy also states, ¿If the home assumes the responsibility of maintaining an individual¿s financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. For a withdrawal, when the individual is given the money directly, the record shall indicate that funds were given directly to the individual and lastly, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.
Moreover, the policy establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property.The House Manager was trained to review the financial log monthly and make sure the financial purchase log is filled out accurately and completely. The House Manager reports all findings to the CEO to help ensure the best financial keeping practices. The CEO reviews the logs as well and helps recommend budgeting ideas to the Individual. The CEO/Program Specialist may make recommendations for ideas for entertainment/activities when it is within the Individual¿s budget as well. The CEO reports to the owner in regards to financial practices/ideas for entertainment and/or budgeting prior to consulting with the individual.Staff members will be trained on the financial policy and practices at least annually or on an ¿as needed¿ basis by the CEO and/or owner to ensure the Individual Funds and Property Regulations are known and being followed. |
08/20/2019
| Implemented |
| 6400.22(f) | Individual #1's ISP, last updated 6/18/19, states that Individual #1's funds are deposited into the bank account of Direct Service Worker #4, Individual #1's mother. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | On July 23rd, 2019, the owner contacted Individual #1¿s mother, who is Direct Service Worker #4 in regards to the bank account to confirm that the funds deposited into the account are only Individual #1¿s funds. The account was open June 19th, 2014. The funds in this account are no longer commingled because only Individual #1¿s funds are deposited into this account and only his/her expenses are paid with this account.
On August 26th, 2019, DSW#4 provided documentation from the bank stating when the account was opened, as well as the balance. The statement provided also shows that only the SSA Treasury check was deposited into the account in July 2019 and all of the expenses relate to Individual #1¿s expense for room and board, and dental expenses.
During the week of August 21st, the staff members reviewed the regulation 6400.22 titled, ¿Individual Funds and Property,¿ which is where the company¿s Financial Policy was derived from. The policy states that nobody may prohibit the individual¿s right to manage his/her own finances and that individual funds and property shall be used for the individual¿s benefit.
Additionally, the financial and property record log shall be up-to-date for each individual that includes personal possessions and funds received by or deposited with the home, as well as disbursements made to or for the individual.
Additionally, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person must be accounted for on the financial and property record log.
The home and staff members are aware that there may be no commingling of the individual¿s personal funds and that there may be no borrowing of the individual¿s personal funds by staff persons or by the home. DSW#4 was trained on these important details to ensure that funds are not commingled.
Furthermore, the home¿s financial policy also states, ¿If the home assumes the responsibility of maintaining an individual¿s financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. For a withdrawal, when the individual is given the money directly, the record shall indicate that funds were given directly to the individual and lastly, documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.
Moreover, the policy establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property.
Staff members will be trained on financial policy/practices at least annually or on an ¿as needed¿ basis by the CEO and/or owner. |
08/26/2019
| Implemented |
| 6400.43(b)(4) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, has not demonstrated a responsibility for the administration and general management of the home as evidenced by a failure to: ensure direct service workers were properly trained in medication administration, ensure an orientation to newly hired staff, ensure implementation of policies and procedures, ensure criminal background checks are completed timely, and ensure complete and accurate health examinations for individuals and staff. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | After the inspection was conducted on July 23rd, 2019, the owner and CEO/Program Specialist acknowledged the violations and dissected all of the 6400 Regulations pertaining to each violation, not only for training and knowledge purposes, but also to brainstorm ideas on how to comply with the regulations most effectively. By reviewing the violations together, the owner and CEO/Program Specialist were able to acknowledge what needed to be changed to ensure compliance and were able to formulate and implement a plan of correction in accordance with the regulations in this chapter for each violation. Following suit, trainings were planned and conducted throughout July and August of 2019 to ensure all staff members were aware of the violations to teach staff members what the team may need to improve on and do differently. Additionally, the trainings allowed staff to familiarize themselves with new policies, procedures and protocols to follow. Throughout July and August of 2019, the CEO/PS has received an array of trainings in administration and general management of the home, as well as many trainings in direct relation to the recent violations in order to ensure compliance with this chapter.
The CEO/PS has been instructed by the owner to study and familiarize himself/herself with the regulations to ensure compliance with this chapter. The CEO/Program Specialist has been working more closely with the owner and House Manager. Communication is key within all parties to grow, develop, maintain and excel and to ensure compliance. It is also important so that each party understands their duties and who they are to report to.
Additionally, the CEO/PS and the owner reviewed the regulations under 6400.43 titled, ¿Chief Executive Officer,¿ as well as the regulations under 6400.44 named, ¿Program Specialist¿ to ensure requirements under these regulations are being carried out & the employee is fulfilling the job requirements. The CEO shall be responsible for the administration and general management of the home, including the following: the implementation of policies and procedures, admission and discharge of individuals, safety and protection of individuals.
The CEO must regulate the recent documents, policies and procedures that have been implemented and see how well they are working in regards to ensuring compliance within the home. The CEO will be able to ensure DSW are properly trained in medication administration, ensure an orientation was completed to newly hired staff, ensure implementation of policies and procedures, ensure criminal background checks are completed timely, and ensure complete and accurate health examinations for individuals and staff. Additionally, the owner, CEO and House Manager will meet at least monthly or on an ¿as needed¿ basis to ensure compliance and success within the home and this chapter. The meetings will consist of reviews of trainings and ideas for training, as well as assessment reviews/meetings, ISP reviews/meetings, and progress note reviews, well as verbal updates on the individual. This will enable these parties to create goals, ensure compliance and measure their goals as well. Additionally, policies and procedures will be reviewed as well to measure what is working well, what is not well and what may need to be changed. Moreover, the House Manager, CEO and owner will be able to review admissions and discharges of individuals and ensure all of the required documentation is accounted for. Additionally, all parties will be able to brainstorm new ideas to help the home¿s admission and discharge process operate more smoothly. Furthermore, the safety and protection of individuals will be reviewed and evaluated to ensure the safety and well-being of not only the individuals, but also the staff. Any staff and/or Participant's notes, concerns and suggestions will be addressed at the monthly meetings as well. Moreover, The CEO will oversee the HM & the owner will oversee both |
08/15/2019
| Implemented |
| 6400.62(a) | A 3.57 Liter bottle of Tandil concentrated bleach with the instructions "call Poison Control or doctor immediately for treatment advice if swallowed" was unlocked and accessible in the cabinet under the sink in the bathroom off of the kitchen in the home. Individual #1 has not been assessed to be able to use or avoid poisonous materials. Individual #1's ISP, last updated 6/18/19, states that Individual #1 is not able to use/avoid poisonous materials and may ingest them. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On July 23rd, 2019, locks and chains were purchased to keep poisonous materials locked so the materials are inaccessible to Individual #1. All poisonous materials, such as the concentrated bleach in the bathroom were placed under the kitchen sink and locked immediately.During the week of July 23rd, 2019, after the inspection, direct service workers were informed by the owner of the precautionary measure taken to lock potentially harmful materials. They were also trained on the new location of any cleaning supplies or items classified as poisonous materials. The direct service workers were also trained that whenever any substance or materials have instructions reading, "call Poison Control or doctor immediately for treatment advice if swallowed," then that substance is classified as a poisonous material and must be locked. Additionally, direct service workers were instructed to ensure the cabinet is locked at the beginning and at the end of every shift to solidify the health and safety of the Individual. Additionally, all staff members were trained on 6400.62 Regulation titled ¿Poisons.¿ Staff members were trained that poisonous materials shall be kept locked or made inaccessible to individuals and that poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. (Documentation of each individual¿s ability to safely use or avoid poisonous materials shall be in each individual¿s assessment). Staff members were also trained that poisonous materials shall be stored in their original, labeled containers and that poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.On August 9th, 2019, Individual #1 was assessed. Though the Individual has never had any encounters with ingesting harmful poisons, the CEO and owner agreed to keep the chemicals locked as a precautionary measure since Individual #1 may ingest them and is not able to safely use or avoid poisonous materials.The House Manager, CEO and Direct Service Workers will receive training annually or on an ¿as needed¿ basis by the owner. |
07/23/2019
| Implemented |
| 6400.77(b) | The first aid kit did not include tweezers and a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On July 23rd, 2019, tweezers and a thermometer were bought and immediately placed into the First Aid kit.
On July 24th, 2019, the House Manager was trained by the owner on the regulations under 6400.77 for ¿First Aid Kit.¿ He/She was retrained on where to find the required materials and guidelines for the first aid kit for future reference. Additionally, the House Manager was trained on the ongoing protocol to ensure the first aid kit is in compliance with residential regulations, as well as what to do if any materials are missing and/or need replenished.
On the first day of every month, the House Manager will check the First Aid kit to ensure it contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, (if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served). If any of the required materials are missing or need replenished, the House Manager will do so and notify the owner of the replenishment. Training the House Manager on the first aid kit will be conducted annually or on an ¿as needed¿ basis by the owner. [On 9/13/19, the Department found the first aid kit to contain all required items and accessible. (AES,HSLS on 9/16/19)] |
07/23/2019
| Implemented |
| 6400.113(a) | Individual #1, date of admission 4/1/2019, was not instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures upon admission. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | On July 23rd, 2019, Individual #1 was instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures even though he/she does not acknowledge the instructions and would need assistance for all of the above referenced procedures.
On July 23rd, 2019, a General Fire Safety Acknowledgement Form was created to confirm an individual (including an individual 17 years of age or younger), has been instructed in the individual's primary language or mode of communication, in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The Individual or parent/guardian shall sign and date the document to confirm all of the above mentioned procedures were addressed, despite the Individual¿s comprehension and communication abilities.
Additionally, to ensure the individual was instructed in all of the processes upon initial admission and reinstructed annually, the General Fire Safety Acknowledgement Form was added to the Initial Admission Checklist (the ¿Initial¿ Admission Checklist is used ongoing as well for re-instruction confirmations) on July 25th, 2019 .
On July 25th, 2019, the CEO and House Manager were trained by the owner on this form in addition to the checklist. The House Manager shall review the procedures and details on the form with the Individual and/or their parent/guardian. The House Manager reviews the General Fire Safety Acknowledgement Form for accuracy and completion. Next, the House Manager places their initials and the date next to the bullet titled General Fire Safety Acknowledgement Form on the Initial Admission Checklist.
Upon the House Manager¿s review, the CEO examines the form to ensure its completion. After the House Manager checks off, initials, and dates all of the tasks and/or forms have been accounted for, the CEO reviews the checklist and participant¿s file to ensure all of the required documentation is present. The CEO then places their initials and date on the Initial Admission Checklist. The form is then placed in the Individual¿s file.
Moreover, the CEO and House Manager also received training on the regulations under 6400.113 titled, ¿Fire Safety Training for Individuals¿ to aid in ensuring compliance.
The plan of correction will ensure individuals are instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures upon admission.
The CEO and house manager will be trained on this process by the owner at least annually or on an ¿as needed¿ basis. Additionally, the Fire Safety Training for Individual regulations will also be reviewed for compliance. |
07/23/2019
| Implemented |
| 6400.141(a) | Individual #1, date of admission 4/1/19, had an initial physical examination completed on 6/19/19. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | On July 25th, 2019, an ¿Initial Participant Admission Checklist¿ was designed to ensure all required documents and records are obtained and on-file with the participant. Upon admission, all documents on the checklist must be accounted for in the participant¿s file. The House Manager reviews the checklist and puts a check-mark, as well as their initials, and the date next to each characteristic on the checklist to ensure we have all of the necessary components of the checklist. The checklist is designed to ensure the physical examination is conducted in a timely manner.
The checklist includes things such as accounts for unusual incident reports relating to the individual, physical examinations, dental examinations, dental hygiene plans, and assessments.
Additionally, the bulletin includes a confirmation of the copy of the invitation to: the initial ISP meeting, the annual update meeting, and the ISP revision meeting.
Moreover, the bulletin accounts for a copy of the signature sheets for: the initial ISP meeting, the annual update meeting, and the ISP revision meeting. The checklist also confirms a copy of the current ISP.
It also includes documentation of ISP reviews and revisions including the following: ISP review signature sheets, recommendations to revise the ISP, ISP revisions, notices that the plan team member may decline the ISP review documentation and requests from plan team members to not receive the ISP review documentation.
Content discrepancy in the ISP (the annual update or revision under) is also reviewed, along with restrictive procedure protocols and records related to the individual, copies of psychological evaluations (if applicable) and recreational and social activities provided to the individual.The checklist also includes a bulletin to confirm the Individual¿s emergency information is easily accessible at the home and includes the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. The bulletin ensures the name, address and telephone number of the individual¿s physician or source of health care are accounted for, as well as the name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.The agenda also includes a checkbox for a release of information form to be on file if applicable.After the House Manager checks off, initials, and dates all of the tasks and/or forms have been accounted for, the CEO reviews the checklist and participant¿s file to ensure all of the required documentation is present. The CEO then places their initials and date on the Initial Participant Admission Checklist.
Furthermore, the CEO and House Manager are both aware of this admission confirmation process and received adequate training on the importance of the checklist and documentation, as well as what procedures are required with this process on July 25th 2019.During the week of August 21st, 2019, all staff including the Direct Service Workers, CEO and House Manager were trained by the owner on the regulations from 6400.141 titled, ¿Individual Physical Examination.¿ The regulations were reviewed to ensure all staff members know and understand the required documentation needed for the Individual, as well as the time frame associated with tasks/documentation and when they should be completed. This plan of correction will ensure physical examinations are completed within 12 months prior to admission and annually thereafter. The CEO and House Manager will be trained by the owner review the Individual Health Regulations at least annually or on an ¿as needed¿ basis. The owner will stress emphasis on dates physical examinations (along with other required documentations) are required to be completed initially and thereafter. |
07/25/2019
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination, dated 6/19/19, does not include a record of immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM to ensure all immunizations are up-to-date as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. On August 26th, 2019, the home received a copy of Individual #1¿s Immunization record. It was immediately placed in the individual¿s file.Any Immunization needed will be done according to the regulation 6400.141 titled, ¿Individual Physical Examination¿ under Individual Health. The regulation states, the physical examination shall include: A review of previous medical history, a general physical examination, as well as immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.During the week of July 25th, 2019, the Hiring Manager and CEO received training from the owner in regards to ensuring all documentation pertaining to the physical examinations, (in particular, the immunization record), is included in an Individual¿s file upon admission. Moreover, on July 25th, 2019, an Initial Admission Checklist page was made to ensure all required documents have been submitted and completed upon admission of an individual into the home. Additionally, the House Manager and CEO were trained by the owner on the checklist, its importance and follow-up procedures to ensure all bulletins on the checklist have been accounted for. Along with an array of trainings and documentation that are bulleted on the checklist, the checklist includes a bullet titled, ¿Immunizations.¿ The House Manager will review the checklist and ensure that all the required documentation has been received and completed prior to an Individual¿s admission. The House Manager must initial and date the checklist to confirm that immunizations have been completed and immunization records have been filed in the individual¿s file. Upon doing so, the CEO will review the individual¿s immunization records and ensure they are up-to-date as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The CEO will initial and date the checklist to confirm all items listed have been received and accounted for. Next, the CEO will contact and inform the owner once all required items and documentation are received.Moreover, the House Manager and CEO will be trained by the owner on Individual Physical Examination regulations at least annually or on an ¿as needed¿ basis to ensure compliance with physical examinations in regards to immunization records. The protocol of the checklists will also be reviewed to ensure the House Manager and CEO are following proper procedures.[On August 29, 2019, physical examination for Individual #1 was updated to include missing information. Upon competition of all individuals' physical examinations, a designated staff persons educated in the requirements of individuals' physical examinations shall audit all individuals' current physical examinations to ensure all required information is included. Missing information shall immediately be obtained. (AES,HSLS on 9/16/19)] |
08/26/2019
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, dated 6/19/19, does not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM. A vision and hearing test will be conducted at this appointment and placed in Individual #1¿s file.
During the week of August 21st, 2019, all staff including the Direct Service Workers, CEO and House Manager were trained by the owner on the regulations from 6400.141 titled, ¿Individual Physical Examination.¿ The regulations were reviewed to ensure all staff members know and understand the required documentation needed for the Individual. Additionally, staff was trained to ensure the form is filled out by the doctor in its entirety prior to leaving the doctor¿s office.Additionally, the Individual Physical Examination Form that was updated on August 21st, 2019 will be used at the Individual¿s physical examination because it includes the required components of the Individual Physical Examination regulations for licensed residential homes. The form includes a section for notes and results for vision and hearing screenings. The form shall be used for individuals 18 years of age or older, as recommended by the physician. Upon receiving the completed Individual Physical Examination Form, the staff member was trained to relay the form and any information from the appointment to the House Manager. The House manager then reviews the form and ensures is filled out completely before placing it in the Individual¿s file. The House Manager relays all of the information to the CEO and owner within 24 hours of the appointment.
To help ensure compliance, all staff members will be trained at least annually or on an ¿as needed¿ basis by the owner in regards to the Individual Health Regulations, along with the physical examination form, appointment procedures and who a staff member is obligated to report to.[On August 29, 2019, physical examination for Individual #1 was updated to include missing information. Upon competition of all individuals' physical examinations, a designated staff persons educated in the requirements of individuals' physical examinations shall audit all individuals' current physical examinations to ensure all required information is included. Missing information shall immediately be obtained. (AES,HSLS on 9/16/19)] |
08/21/2019
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination, dated 6/19/19, does not include a Tuberculin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM. Any additional documentation needed pertaining to the individual¿s health history will be obtained at the appointment.On August 2nd, 2019, Individual #1¿s mother was contacted to obtain the Tuberculin Testing Results. However, she was unable to obtain them at the time. On August 26th, 2019, the home received a record copy of Individual #1¿s Tuberculin skin testing confirming that it was completed on 3/21/2018. Consequently, the Tuberculin skin testing by Mantoux method with negative results is to be completed every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Moreover, the Individual still has some time until they are required to complete another TB Test based on the regulation 6400.141, titled ¿Individual Physical Examination.¿ Moreover, the copy of the record for the TB Test was placed in the individual¿s file. Details from the test results will be obtained from the owner at the upcoming doctor¿s appointment and will be placed into the Individual¿s file for the House Manager and CEO to review.
Moreover, on July 25th, 2019, an Initial Admission Checklist page was made to ensure all required documents have been submitted upon admission of an individual into the home. Additionally, the House Manager and CEO were trained by the owner on the checklist, its importance and follow-up procedures to ensure all bulletins on the checklist have been accounted for. In order to ensure all documentation is accounted for in an Individual¿s file, the Initial Admission Checklist will be utilized which has a bullet titled, ¿Tuberculin Skin Testing by Mantoux method (with negative results is to be completed every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted).The House Manager will review the checklist and ensure that all the required documentation has been received and completed prior to an Individual¿s admission. The House Manager must initial and date the checklist to confirm that the TB Testing has been completed and the TB Test records have been filed in the individual¿s file.Upon doing so, the CEO will review the individual¿s TB Testing records and ensure they are in compliance based on the Individual Physical Examination regulations. The CEO will initial and date the checklist to confirm all items listed on the checklist have been received and accounted for. Next, the CEO will contact and inform the owner once all required items and documentation are received.
Moreover, the House Manager and CEO will be trained by the owner on Individual Physical Examination Regulations at least annually or on an ¿as needed¿ basis to ensure compliance with physical examinations in regards to immunization records. The protocol of the checklists will also be reviewed to ensure the House Manager and CEO are following proper procedures.[On August 29, 2019, physical examination for Individual #1 was updated to include missing information. Upon competition of all individuals' physical examinations, a designated staff persons educated in the requirements of individuals' physical examinations shall audit all individuals' current physical examinations to ensure all required information is included. Missing information shall immediately be obtained. (AES,HSLS on 9/16/19)] |
08/26/2019
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, dated 6/19/19, does not include an assessment of the individual's health maintenance needs and/or the need for bloodwork at recommended intervals. | 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. | Roughly a month prior to the inspection (June 23rd, 2019), a psychiatric appointment was made with Individual #1¿s psychiatrist for October 9th, 2019 at 4:15PM. On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM.On August 21st, 2019, the section labeled, ¿Individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals¿ was added to the Individual¿s Physical Examination Form that was created in July to ensure Individual #1 and future Individuals will have all of the required physical examination information. This form will be used at the appointment on August 29th to obtain the required information.During the week of August 21st, 2019, all staff (DSW, HM, CEO) were trained by the owner on the update to the Individual Physical Examination Form and the importance of including Individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The regulations from 6400.141 titled, ¿Individual Physical Examination¿ were reviewed to ensure all staff members know and understand the required documentation needed for the Individual. Additionally, staff was trained to ensure the form is filled out by the doctor in its entirety prior to leaving the doctor¿s office, as well as solidifying that a follow-up appointment (day/time) (in compliance with ODP¿s regulations for regulatory health appointments) are set-up while at the doctor appointment.
Additionally, staff was instructed on how to take any additional notes (as needed) at the doctor¿s appointment. All staff members were trained on the importance of all parties in attendance at the doctor¿s visit and how all staff members in attendance shall initial and date the physical examination form. Moreover, staff was trained on informing the House Manager on dates of follow-up appointments, as well as any medication changes and significant take-aways from the appointments. The House Manager relays that information to the CEO and owner within 24 hours of the appointment and places the documentation in the Individual¿s file.
To help ensure compliance, all staff members will be trained at least annually or on an ¿as needed¿ basis by the owner in regards to the Individual Health Regulations, along with the physical examination form, appointment procedures and who a staff member is obligated to report to.[On August 29, 2019, physical examination for Individual #1 was updated to include missing information. Upon competition of all individuals' physical examinations, a designated staff persons educated in the requirements of individuals' physical examinations shall audit all individuals' current physical examinations to ensure all required information is included. Missing information shall immediately be obtained. (AES,HSLS on 9/16/19)] |
08/21/2019
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 6/19/19, does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Roughly a month prior to the inspection (June 23rd, 2019), a psychiatric appointment was made with Individual #1¿s psychiatrist for October 9th, 2019 at 4:15PM. On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM.On August 21st, 2019, the statement, ¿Medical information pertinent to diagnosis and treatment in case of an emergency¿ was added to the Individual¿s Physical Examination Form that was created in July to ensure Individual #1 and future Individuals will have all of the required physical examination information. This form will be used at the appointment on August 29th to obtain the needed information for emergency purposes.During the week of August 21st, 2019, all staff (DSW, HM, CEO) were trained by the owner on the update to the physical examination form and the importance of including medical information pertinent to diagnosis and treatment in case of an emergency. The regulations from 6400.141 titled, ¿Individual Physical Examination¿ were reviewed to ensure all staff members know and understand the required documentation needed for the Individual. Additionally, staff was trained to ensure the form is filled out by the doctor in its entirety prior to leaving the doctor¿s office, as well as solidifying that a follow-up appointment (day/time) (in compliance with ODP¿s regulations for regulatory health appointments) are set-up while at the doctor appointment. Additionally, staff was instructed on how to take any additional notes (as needed) at the doctor¿s appointment. All staff members were trained on the importance of all parties in attendance at the doctor¿s visit and how all staff members in attendance shall initial and date the physical examination form.
Moreover, staff was trained on informing the House Manager on dates of follow-up appointments, as well as any medication changes and significant take-aways from the appointments. The House Manager relays that information to the CEO and owner within 24 hours of the appointment.To help ensure compliance, all staff members will be trained at least annually or on an ¿as needed¿ basis by the owner in regards to the Individual Health Regulations, along with the physical examination form, appointment procedures and who a staff member is obligated to report to. [On August 29, 2019, physical examination for Individual #1 was updated to include missing information. Upon competition of all individuals' physical examinations, a designated staff persons educated in the requirements of individuals' physical examinations shall audit all individuals' current physical examinations to ensure all required information is included. Missing information shall immediately be obtained. (AES,HSLS on 9/16/19)] |
08/21/2019
| Implemented |
| 6400.151(a) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, does not have a current physical examination. Direct Service Worker #2, date of hire 4/1/2019, does not have a current physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | On August 21st, 2019, the CEO/Program Specialist had his/her physical examination completed. A copy of the physical examination was made and placed in his/her file. On July 23rd, 2019, Direct Service Worker #2 was released until he/she is able to provide the required documentation regarding her physical examination.
On July 23rd, 2019 the House Manager and CEO/Program Specialist were trained by the owner on the regulations under Staff Health. The requirements under 6400.151 titled, ¿Staff Physical Examination,¿ were reviewed to ensure all physical examinations are completed within the designated time frames. Additionally, the regulation addresses, ¿A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Therefore, there is no question which potential employees require a physical examination.Though the CEO/Program Specialist does not work day-in and day-out with the Individual and primarily participates in video calls and/or attends mandatory assessments for the Individual, the CEO/Program Specialist completed his physical to ensure compliance.Moreover, on July 25th, 2019, a checklist page was made to ensure all required documents have been submitted and completed prior to a CEO/Program Specialist and/or Direct Service Worker position being fulfilled. Additionally, the House Manager and CEO were trained by the owner on the checklist, its importance and follow-up procedures to ensure all bulletins on the checklist have been accounted for. Along with an array of trainings and documentation that are bulleted on the checklist, the checklist includes a bullet for physical examination and its documentation. The bullet notes that a physical examination must be done prior to employment and every 2 years thereafter.
The hiring manager will review the checklist and ensure that all the required documentation has been completed prior to the CEO/Program Specialist prior to employment. The hiring manager must initial and date the checklist to confirm the physical examination has been completed and reviewed.
Upon doing so, the owner will be contacted and conduct a review of the CEO/Program Specialist¿s and/or Direct Service Worker¿s file to confirm all of the required documentation has been conducted and/or received. The owner will then initial and date the checklist to ensure all of the documentation has been reviewed in the CEO/Program Specialist¿s and/or Direct Service Worker¿s file.
Moreover, the House Manager and CEO will be trained by the owner on Staff Health Regulations at least annually or on an ¿as needed¿ basis to ensure compliance with the time frames physical examinations must be completed, as well as the content of the test, along with who is required to complete a physical examination and the importance of the required signatures and dates. The protocol of the checklists will also be reviewed to ensure the Direct Service worker and/or CEO/Program Specialist¿s files include all of the documentation one is required to have prior to employment. |
08/21/2019
| Implemented |
| 6400.151(c)(2) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, does not have a current Tuberculin testing. Direct Service Worker #2, date of hire 4/1/2019, does not have a current Tuberculin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | On August 21st, 2019, the CEO/Program Specialist #1 received his/her negative Tuberculin Testing results.
In July of 2019, a standard TB Test Results form was made for all prospective employees to use when having their TB Test conducted and read for uniform purposes. The TB Test Results form also ensures that it includes all of the required signatures and dates by a registered nurse, licensed practical nurse, licensed physician, licensed physician's assistant or certified nurse practitioner. On July 23rd, 2019, Direct Service Worker #2 was released until she is able to provide the required documentation regarding her TB Test. On July 23rd, 2019 the House Manager and CEO were trained by the owner on the regulations under Staff Health. The requirements under 6400.151 titled, ¿Staff Physical Examination,¿ were reviewed to ensure all physical examination requirements are included in the physical examination form, are in compliance and are being completed within the designated time frames.
Specifically the regulation addresses that a Tuberculin skin testing by the Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted must be completed.
Upon receiving the filled out TB Test Results, the House Manager reviews the results on the form and ensures it is filled out accurately and completely then it is placed into the Direct Service Worker¿s file or CEO/Program Specialist¿s file.On July 25th, 2019, a checklist page was made to ensure all required documents and training have been submitted and completed prior to a CEO/Program Specialist and/or Direct Service Worker position being fulfilled. Additionally, the House Manager and CEO were trained by the owner on the checklist, its importance and follow-up procedures to ensure all bulletins on the checklist have been accounted for. To name a few, the checklist includes: Staff Orientation, Receivement of the Training Syllabus, Administration Training (CEO: at least 24 hours annually) and Human Services¿ Training (PS & DSW who are employed more than 40 hours per month shall have at least 24 hours annually). Additionally, the checklist includes training in the areas of intellectual disability, the principles of integration, as well as the rights and program planning and implementation (within 30 calendar days after the day of initial employment or within 12 months prior to initial employment). The checklist also addresses receivement of a background check (prior to hiring date). The checklist also includes the conduction and documentation from Medicheck, SAMS and LEIE check (these checks are done prior to hiring date and monthly thereafter). It also includes a bulletin to ensure a physical examination and TB Test (prior to employment and every 2 years thereafter) was completed and the results were received and reviewed.The hiring manager will review the checklist and ensure that all the required documentation and trainings have been completed prior to the CEO/Program Specialist starting their first shift. The hiring manager will also make sure that all training record logs are filled out for accuracy and completion. The hiring manager must initial and date the checklist to confirm the required documentation and trainings have been completed. Upon doing so, the owner will be contacted and conduct a second review of the CEO/Program Specialist¿s and/or Direct Service Worker¿s file to confirm all of the required documentation, trainings and orientations have been conducted and/or received. The owner will then initial and date the checklist to ensure all of the documentation has been reviewed in the CEO/Program Specialist¿s and/or Direct Service Worker¿s file. Moreover, the House Manager and CEO will be trained by the owner on Staff Health Regulations at least annually or on an ¿as needed¿ basis. |
08/21/2019
| Implemented |
| 6400.151(c)(3) | The physical examination, dated 12/7/18 for Direct Service Worker #3, date of hire 4/1/2019, had does not address communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | In July of 2019, a standard physical examination form was made to include the specific verbiage addressing communicable diseases. The statement says that the staff person is free of communicable diseases. The statement is followed by a line to include the physician¿s signature, as well as the date. The Physical Examination Form is sent and/or given to all employees and is required to be filled out when completing their physicals. In July of 2019, the House Manager and CEO were trained by the owner on the form and its importance. All future physical examinations, will use the form. Additionally, the House Manager and CEO must remind the employee (for 2 year physical examination) or potential employee that the registered nurse, licensed physician, certified nurse practitioner or licensed physician¿s assistant is required to complete the physical and sign and date the form, and make sure that the health care provider addresses the communicable disease statement. Upon receiving the filled out form, the House Manager reviews the details on the form and ensures it is filled out accurately and completely then it is placed into the Direct Service Worker¿s file. On July 23rd, 2019 the House Manager and CEO were trained by the owner on the regulations under Staff Health. The requirements under 6400.151 titled, ¿Staff Physical Examination,¿ were reviewed to ensure all physical examination requirements are included in the physical examination form, are in compliance and are being completed within the designated time frames. Moreover, the House Manager and CEO will be trained by the owner on Staff Health Regulations at least annually or on an ¿as needed¿ basis to ensure compliance with the time frames physical examinations must be completed, as well as the content of the exam, along with who is required to complete a physical examination. [Immediately and upon competition, the CEO or designee shall audit all staff persons' physical examination to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES,HSLS on 9/16/19)] |
07/15/2019
| Implemented |
| 6400.181(a) | Individual #1, date of admission 4/1/2019, does not have an initial assessment. | 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. | On August 9th, 2019, Individual #1¿s Initial Assessment was completed. On August 23rd, 2019, the Program Specialist was formally trained by the owner on regulation 6400.181 titled, ¿Assessment.¿ However, the PS was instructed to review and know this information beforehand. After reviewing the regulations detailed under the Assessment, the Program Specialist understands all of the details that must be covered in the initial assessment such as an assessment of adaptive behavior and level of skills completed within 6 months prior to admission. The Program Specialist also understands the initial assessment must be completed within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter.
The Program Specialist was trained that the assessment shall be based on assessment instruments, interviews, progress notes and observations. The Program Specialist was trained to sign and date the assessment.
Additionally, the Program Specialist was trained on the details of the assessment that shall be included.
Additionally, the Program Specialist was trained that the individual¿s progress over the last 365 calendar days and current level in the following areas: Health, motor and communication skills, activities of residential living, personal adjustment, socialization, recreation, financial independence, managing personal property, community-integration, as well as the individual¿s knowledge of water safety and ability to swim must be included in the initial assessment.
The training also covered how the program specialist shall provide the assessment to the SC, (as applicable), and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP. Furthermore, on July 25th, 2019, an ¿Initial Participant Admission Checklist¿ was designed to ensure all required documents and records are obtained and on-file with the participant. Upon admission, all documents on the checklist must be accounted for in the participant¿s file. The House Manager reviews the checklist and puts a check-mark, as well as their initials, and the date next to each characteristic on the checklist to ensure we have all of the necessary components of the checklist. The checklist includes the assessment among other required documents and records: Content discrepancy in the ISP (the annual update or revision under) is also reviewed, along with restrictive procedure protocols and records related to the individual, copies of psychological evaluations (if applicable) and recreational and social activities provided to the individual.
The checklist also includes a bulletin to confirm the Individual¿s emergency information is easily accessible at the home and includes the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. The bulletin ensures the name, address and telephone number of the individual¿s physician or source of health care are accounted for, as well as the name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The agenda also includes a checkbox for a release of information form to be on file if applicable.After the House Manager checks off, initials, and dates all of the tasks and/or forms have been accounted for, the CEO reviews the checklist and participant¿s file to ensure all of the required documentation is present. The CEO then places their initials and date on the Initial Participant Admission Checklist. This will ensure the assessment is accounted for.
Moreover, the Program Specialist will be trained by the owner on this regulation at least annually or on an ¿as needed¿ basis to ensure compliance of the time frames assessments must be completed, as well as the content of the assessments. |
08/09/2019
| Implemented |
| 6400.34(a) | Individual #1, date of admission 4/1/2019, was not informed of the individual's rights upon admission. | 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. | On July 23rd, 2019, a form was made to inform Individual #1 of his/her individual rights. The form informs and explains individual rights and the process to report a rights violation to the individual, and persons designated by the individual. On July 24th, 2019, the form was signed by Individual #1 and his/her designated person.
On July 23rd, 2019, the CEO was trained on the form and the process involved with the form to ensure compliance. To make sure an individual is informed of their individual rights upon admission, this form is listed on the ¿Participant¿s Checklist.¿ The CEO will review the checklist and confirm that the individual, and persons designated by the individual have received and signed off on this form. The CEO will check the signed form for completion and accuracy. The form will then be placed in the participant¿s file for reference. Before admission to the home, the owner will review the checklist and confirm the documentation is included and filled out for accuracy and completion. In the training, the owner reviewed the regulation 6400.32 titled ¿Rights¿ with the CEO which states that an individual may not be deprived of rights. Additionally, the owner covered the regulation 6400.33 titled, ¿Rights of the Individual.¿ Therefore, the form made on July 23rd covers all of the rights of the individual including: An individual may not be neglected, abused, mistreated or subjected to corporal punishment, an individual may not be required to participate in research projects, an individual has the right to manage personal financial affairs, an individual has the right to participate in program planning that affects the individual, an individual has the right to privacy in bedrooms, bathrooms and during personal care, an individual has the right to receive, purchase, have and use personal property, an individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual¿s own choice, an individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary, an individual has the right to unrestricted mailing privileges, an individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections, an individual has the right to practice the religion or faith of the individual¿s choice, an individual has the right to be free from excessive medication, and an individual may not be required to work at the home, except for the upkeep of the individual¿s personal living areas and the upkeep of common living areas and grounds. The Individual, and persons designated by the individual shall be informed and explained of individual rights and the process to report a rights violation annually by the CEO. Additionally, the CEO will review the regulations associated with an Individual¿s Rights on an ¿as needed¿ basis and will continue to receive training annually on the forms and regulations. |
07/24/2019
| Implemented |
| 6400.46(a) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, was not trained prior to working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside of the building or within a fire safe area in the event of an actual fire, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The fire safety training documentation for Direct Service Worker #2, date of hire 4/1/2019, was not dated; therefore, compliance could not be measured. The fire safety training documentation for Direct Service Worker #3, date of hire 4/1/2019, was not dated; therefore, compliance could not be measured. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | On July 24, 2019, a new signature page was made to ensure the accuracy of training records. The record log includes the training course(s) taken, along with spaces for an employee to print and sign their name, as well as a space to include the date. Moreover, this will aid in providing proof of fire safety compliance by including the date column on the template for the training records to ensure record keeping accuracy. On July 24th, 2019, the CEO and House Manager were trained on the new Training Record Log by the owner. They were trained on the Training Log¿s importance, as well as the processes involved for confirming an employee accurately completed the Training Record Log in its entirety before anyone leaves the facility where the training was held. With any employee training, a head count will be taken twice; once by the trainer and once by the CEO, owner, or designated employee for that particular meeting. Additionally, the amount of names listed on the signature page will be counted twice to ensure that the number of signatures match the head count, prior to anyone leaving the training facility.
The CEO or House Manager will review the Training Record Log and make sure that every individual accounted for at the meeting signed the record document legibly and in its entirety. The CEO or House Manager then gives the Training Record Log to the owner who confirms the log is filled out for accuracy and completion.
The CEO, House Manager and direct service workers will be trained by fire safety expert on fire safety annually or on an ¿as needed¿ basis Additionally, the regulations pertaining to staffing, staff training, as well as proper record keeping will be an area of focus for the House Manager and CEO. The House Manager and CEO will continue to be trained on these regulations at least annually or on an ¿as needed¿ basis to ensure understanding and compliance.
On August 9th, 2019, the CEO/Program Specialist was trained in general fire safety by a fire safety expert and passed the Fire Safety Exam. Additionally, the CEO/Program Specialist was trained in evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Though the CEO/Program Specialist only comes into contact with the Individual on an ¿as needed¿ basis for things such as assessments and has not tangibly been in the licensed residential home, the company now understands it is still required for the CEO/Program Specialist to partake in all of the trainings listed above in relation to general fire safety trainings. The company also learned not to make assumptions based on who may be required to have trainings due to different circumstances and who will not. Moreover, at the training on July 23rd, 2019, the owner, Hiring Manager and CEO established the protocol of utilizing resources such as www.myodp.org and/or contact ODP¿s Administrative Entities, to ensure compliance. [Direct Service Worker #2 is no longer an employee of the agency. (AES,HSLS on 9/16/19)] |
08/09/2019
| Implemented |
| 6400.46(c) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, was not trained in first aid techniques prior to working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | On August 9th, 2019, the CEO/Program Specialist received training in first aid techniques. Additionally, the CEO/Program Specialist is scheduled to participate in another mandatory training in First Aid, as well as CPR and the Heimlich on August 28th, 2019 to receive his/her certification in First Aid and CPR (including Heimlich). Moreover, the Program Specialist will not be transporting any Individuals. On July 25th, 2019, a checklist page was made to ensure all documents/training have been submitted and completed prior to a position being fulfilled and working with the Individual. The checklist addresses the requirements for the CEO/Program Specialist, as well as direct service worker positions.all Moreover, it also includes bulletins on the ongoing agenda related to future documentation and ongoing training needed once the initial training and documentation are received.
Additionally, the 6400.46 Regulations relating to ¿Staff Training¿ were reviewed with the owner to make sure the Hiring Manager, House Manager and CEO understand the processes involved when hiring individuals, as well as the necessary documentation and training that is involved. Moreover, it reiterates to the CEO and House Manager the ongoing training requirements and required documentation for all staff members.
One of the items on the CEO/Program Specialist¿s bulletin include training in first aid techniques prior to working with individuals. Consequently, the bulletin addresses that Program Specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. Additionally, the bulletin includes orientation, the receivement of the training syllabus describing the orientation, as well as the CEO having at least 24 hours of training relevant to human services or administration annually. Additionally, (when applicable), program specialist and direct care staff who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. The checklist also includes that program specialist and direct care staff shall have training in the areas of intellectual disability, the principles of integration, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.
The bulletin also confirms the Program Specialist is trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Additionally, the checklist assures the Program Specialist is trained annually by a fire safety expert.The checklist also addresses Program Specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques.
Moreover, records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept with the checklist.
The Hiring Manager will review the checklist and ensure that all the required documentation and trainings have been completed prior to the CEO/Program Specialist starting their first shift. The hiring manager will also make sure that all training record logs are filled out for accuracy and completion. The hiring manager must initial and date the checklist to confirm the required documentation and trainings have been completed.
Hiring Manager trained annually |
08/09/2019
| Implemented |
| 6400.51(a)(1) | Chief Executive Officer/Program Specialist #1, date of hire 4/1/2019, did not have an orientation. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | On August 9th, 2019, The CEO/Program Specialist completed an orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. The CEO/Program Specialist was trained by the owner. Though the 6400 Regulations, as well as the violations from the inspection conducted on July 23rd, 2019 were reviewed via phone between the CEO and owner on July 23rd, 2019, they were reviewed again on August 9th. The training and review was conducted to not only understand the violations from the inspection more in depth, but also to brainstorm more ideas to fulfill a sufficient plan of corrections to avoid violations in the future that are in constant correlation to management, program, administrative and fiscal persons.Any future CEO/Program Specialist will complete the required training prior to working alone with individuals, and within 30 days after hire.
On July 25th, 2019, a checklist page was made to ensure all documents and training has been submitted and completed prior to a CEO/Program Specialist position being fulfilled. The hiring manager will review the checklist and ensure that all the required documentation and trainings have been completed prior to the CEO/Program Specialist starting their first shift. The hiring manager will also make sure that all training record logs are filled out for accuracy and completion. The hiring manager must initial and date the checklist to confirm the required documentation and trainings have been completed. Upon doing so, the owner will be contacted and conduct a second review of the CEO/Program Specialist¿s file to confirm all of the necessary trainings and orientations have been conducted. The owner will then initial and date the checklist to ensure all of the documentation has been reviewed in the CEO/Program Specialist¿s file. Then the CEO/Program Specialist may officially work alone with Individuals (when applicable) and carry out all of their managerial, administrative, and program duties, as well as their duties pertaining to fiscal staff person(s) duties. |
08/09/2019
| Implemented |
| 6400.51(a)(3) | The orientation documentation for Direct Service Worker #2, date of hire 4/1/2019, was not dated; therefore, compliance could not be measured. The orientation documentation for Direct Service Worker #3, date of hire 4/1/2019, was not dated; therefore, compliance could not be measured. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | On July 24, 2019, a new signature page was made to ensure the accuracy of training records. The record log includes the training course(s) taken, along with spaces for an employee to print and sign their name, as well as a space to include the date. Moreover, this will aid in providing proof of staff orientation compliance by including the date column on the template for the training records to ensure record keeping accuracy.
On July 24th, 2019, the CEO and House Manager were trained on the new Training Record Log by the owner. They were trained on the Training Log¿s importance, as well as the processes involved for confirming an employee accurately completed the Training Record Log in its entirety before anyone leaves the facility where the training was held.
With any employee training, a head count will be taken twice; once by the trainer and once by the CEO, owner, or designated employee for that particular meeting. Additionally, the amount of names listed on the signature page will be counted twice to ensure that the number of signatures match the head count, prior to anyone leaving the training facility.
The CEO or House Manager will review the Training Record Log and make sure that every individual accounted for at the meeting signed the record document legibly and in its entirety. The CEO or House Manager then gives the Training Record Log to the owner who confirms the log is filled out for accuracy and completion.
The CEO, House Manager and direct service workers will be trained by the owner on orientation knowledge annually or on an ¿as needed¿ basis by means of verbal and hands-on questionnaires in relation to topics covered in the staff orientation which staff members will sign off on with the new, templated Training Record Logs.
Additionally, the regulations pertaining to staffing, staff training, as well as proper record keeping will be an areas of focus for the House Manager and CEO. The House Manager and CEO will continue to be trained on these regulations at least annually or on an ¿as needed¿ basis to ensure understanding and compliance.
Though Direct Service Worker #2 and Direct Service Worker #3 both completed an orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons within 30 days after hire, the date was not recorded so this could not be measured.
On July 24th, 2019, Direct Service Worker #3 was retrained on the staff orientation by the owner by means of a verbal and hands-on questionnaire relating to the topics covered at the staff orientation. The Direct Service Worker was able to answer every question correctly, illustrating his/her knowledge of the staff orientation information. This training was completed to ensure DSW#3 is aware and knowledgeable on all staff orientation topics, since the staff orientation was unable to be measured on the initial staff orientation documentation due to the signatures not being accompanied by the date the orientation was taken. Upon training review of the staff orientation, DSW#3 dated his training material in front of the owner. The House Manager confirmed accuracy and completion of the Training Record Log after DSW#3 signed it.
By July 24th, 2019, Direct Service Worker #2 was no longer employed by the company or else he/she would have received a verbal and hands-on questionnaire on the topics covered at the staff orientation as well.
By August 15th, 2019, all employees were trained on the staff orientation topics by means of a hands-on and verbal questionnaire. |
07/24/2019
| Implemented |
| 6400.162(a) | Direct Service Worker #3, date of hire 4/1/2019, administered Quetiapine 100 mg, Clonazepam 1 mg, and Citalopram 10 mg to Individual #1 at approximately 8 AM on 7/4/19, 7/6/19, 7/11/19, and 7/18/19. Direct Service Worker #3 is not qualified to administer medications. In addition, as of 7/23/19 the agency did not employ staff persons qualified to administer medications to Individual #1, date of admission 4/1/19. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | On July 29th, 2019, AMA Support Services¿ trainer aided in distributing medications all week until staff members were trained. On July 30th, 2019, a nurse was hired to administer medications on an on-call/as needed basis.
On July 30th and July 31st of 2019, three staff members received medication administration training and passed the examinations from AMA Support Services to become certified in medication administration. By August 6th, 2019, all three staff members completed and passed their medication observations and became certified in medication administration.After six months of the initial medication administration certification (roughly February of 2020), one of the trained medication administration employees will be eligible to; and will become a Practicum Observer to assist with future medication observations. On July 30th, 2019, the House Manager and CEO were trained by the owner on which team members are med trained and/or will be med trained in order to ensure Individual #1 is consistently administered his medications from a med trained staff member on each shift. Moreover, when a House Manager is scheduling shifts for the week, there must be one medication administration staff member on a shift, as well as someone who is trained on medication administration (such as a nurse), on-call to administer medications every week. The House Manager and CEO were also trained on how to mark the calendar and receive notifications/alerts when an employee is to participate in their annual practicum for medication administration to ensure all med trained staff members complete this required practicum in a timely matter to help streamline compliance. Before releasing weekly schedules, the House Manager receives approval from the CEO to post and carry out the weekly schedule in order to ensure all of the staffing standards are being met on the schedule. The house manager and CEO will be trained by the owner on the importance of sufficient staff scheduling annually or on an ¿as needed¿ basis.
Additionally the medication administration staff members will be trained annually or on an ¿as needed¿ basis. The med trained staff members will also have an annual practicum to complete (prior to the date of certification on their certificate, which is logged and tracked in the company computer in order to alert the House Manager and CEO when their training needs to be scheduled), and consists of 4 MAR Reviews and 2 medication observations.
Additionally, the House Manager, CEO and owner reviewed this regulation in order to ensure individuals who require med trained staff members to administer medications will have employees med trained for the Individual prior to rendering services. The House Manager and CEO must review this regulation prior to admitting an Individual into the home and rendering services. Upon review, the House Manager and CEO conclude what the Individual¿s self-administration status is. This information is then relayed to the owner and proper action is taken in regards to training and staffing to ensure compliance. |
07/25/2019
| Implemented |
| 6400.163(d) | Individual #1's prescription medications including Clonazepam 1 mg, Acetaminophen 325 mg, Sertraline 100 mg were unlocked, unattended, and available in the upper cabinet to the left of the refrigerator in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On July 23rd, 2019, locks and chains were bought, as well as a tool-box to secure medications. Moreover, if a medication is an antipsychotic drug, it is double locked in the tool-box since it is considered a controlled substance. The other medications are locked in the cabinet above the sink next to the tool-box within the same cabinet. All prescription medications and syringes are locked in this space. On July 29th and July 30th of 2019, three staff members completed and passed the Medication Administration Training conducted by a certified Medication Administration Trainer at AMA Support Services. On July 29th 2019, the importance of ensuring the medication cabinet is always locked when medication is not being administered was reiterated to the medication administration staff members, as well as all other staff members.During the week of July 23rd, 2019, after the inspection, all staff members were trained before their shift by the owner, on the importance of maintaining a locked medicine cabinet, as well as the relocation of the prescription medications and/or syringes, which were relocated within the kitchen in the cabinet above the sink. Staff was also trained on what prescribed medication(s) are considered controlled substances. Therefore, any controlled substances must be double-locked; once in the tool-box, and once in the cabinet holding the tool-box.Additionally, all staff members were trained to check the cabinet before and after all shifts and to confirm with their shift partner that the lock is secured.
During the week of July 30th, 2019, after med training was received, the owner trained all staff prior to their shift that after a med trained employee disperses medications, the med trained staff member must check the lock to make sure the cabinet is locked and the other staff member on shift with them must confirm the lock is fastened as well to ensure the safety of both staff and the Individual. Moreover, staff will be trained at least annually or on an ¿as needed¿ basis by the owner.The Plan of Correction will ensure that prescription medications and syringes (with the exception of epinephrine and epinephrine auto-injectors), shall be kept in a locked cabinet. It will also aid in safeguarding controlled substances by having them double locked. [On September 13, 2019, all medications were in a locked area. (AES,HSLS on 9/16/19)] |
07/23/2019
| Implemented |
| 6400.165(g) | The review of medications prescribed to treat symptoms of a psychiatric illness for Individual #1 was most recently completed on 4/8/19. In addition, this review did not include the reason for prescribing the medication. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Roughly a month prior to the inspection (June 23rd, 2019), a psychiatric appointment was made with Individual #1¿s psychiatrist for October 9th, 2019 at 4:15PM. On August 2nd, 2019, an appointment with Individual #1¿s primary care doctor was made for August 29th at 11:30AM.On August 21st, 2019, a medication document was made to keep an accurate record of the Individual #1¿s doctor appointments and allows the records to be uniform. The medication document includes if a medication is prescribed to treat symptoms of a psychiatric illness, as well as the reason for prescribing the medication, along with the need to continue the medication and the necessary dosage. The Five Rights of Medication are also included on the paper including the right patient, the right drug, the right dose, the right route and the right time. The document also includes any medication changes. The medication document fortifies all of the necessary documentation is accounted for and helps create certainty in regards to the Individual¿s health visit and medication details among staff members, House Managers, the CEO and the owner.
Moreover, the medication document includes the participant¿s name, the doctor¿s name, and the date of the appointment, as well as the date and time of the next (follow-up) appointment that should be no more than 3 months from the date of the present appointment. Staff will be trained to ensure the form is filled out by the doctor in its entirety prior to leaving the doctor¿s office, as well as solidifying that a follow-up appointment and time is set-up while at the doctor appointment. Additionally, staff will be instructed on how to take any additional notes (as needed) at the doctor¿s appointment. All staff members will be trained on the importance of all parties in attendance at the doctor¿s visit initialing and dating the medication document as well.
Furthermore, staff will be trained on where to mark the calendar for all staff members to see for future appointments. Additionally, staff will be trained on informing the House Manager on dates of follow-up appointments, as well as any medication changes and significant take-aways from the appointments. The House Manager relays that information to the CEO within 24 hours and the CEO notifies the owner within 24 hours of receiving the pertinent information.All staff will be formally trained by September 30th, 2019 by the owner. The owner, who is already trained on this Plan of Correction, will be in attendance of all doctor visits in the interim until September 30th of 2019 and will accompany staff members on the interim visits, who will receive verbal and hands-on training.Additionally, to help ensure compliance, staff members will be trained on the medication document and its importance at least annually or on an ¿as needed¿ basis by the owner. The use of the Plan of Correction medication document on the scheduled, upcoming doctors¿ visits will aid staff members in ensuring the reason for prescribing the medication is included. Additionally, the medication document will assist staff and management in ensuring the Individual is being reviewed by a licensed physician at least every 3 months when the Individual is prescribed a medication to treat symptoms of a psychiatric illness. The medication document secures the required documentation regarding the reason for prescribing the medication, the need to continue the medication and the necessary dosage. [Individual #1 had a review of medications to treat symptoms of a diagnosed psychiatric illness on 8/29/19 to included all required information. (AES,HSLS on 9/16/19)] |
06/23/2019
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include the required personal information of color of hair, color of eyes, or identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, Social Security number, race, height, weight, color of hair, color of eyes, identify marks , the language or means of communication spoken or understood by the individual, primary language used in the individual's natural home, the religious affiliation, the next of kin, a current dated photograph. | On July 30th, 2019, the Supports¿ Coordinator sent a copy of the current ISP and it was immediately printed and placed into Individual #1¿s ISP Binder. The current ISP did not include the required personal information of color of hair, color of eyes, or identifying marks. However, to be in immediate compliance, the House Manager manually typed in the required personal information in a different color on the current ISP. On August 23rd, 2019, the owner contacted the SC to have the personal information updated in HCSIS. Both the House Manager and CEO must give the SC a month to update the information in HCSIS and must confirm the ISP was updated after the alloted time period and print a new ISP for the residence.On August 23rd, 2019, the CEO and House Manager were trained by the owner on how to initiate changes in the ISP, who to contact to change or update the ISP, as well as the ISP confirmation processes to follow after a change was submitted to confirm its fruition in the ISP. Additionally, the CEO and House Manager were trained in the 6400 regulations in regards to the personal information that is required in the ISP, as well as the requirements involved in relation to a current dated photograph of the Individual. The CEO and house manager will be trained on this process by the owner at least annually or on an ¿as needed¿ basis so they may continually review ISPs together monthly and ensure the ISPs contain all of the required personal information displayed in the 6400.213 ¿Content of Records¿ Regulation.The plan of correction will ensure that the personal information section of the ISP is reviewed monthly for accuracy and include all of the required personal information in its entirety and completeness for based on the Individual. [On 9/16/19, the required personal information was contained in Individual #1'record. (AES,HSLS on 9/16/19)] |
08/30/2019
| Implemented |
| 6400.213(7) | Individual #1's record did not include a copy of the invitation to Individual's annual ISP meeting on May 30, 2019. Individual #1's record did not include a copy of the current ISP, the ISP in the record was from fiscal year 2018-2019. Individual #1's record did not include a copy of the signature sheet from the ISP meeting on May 30, 2019. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | On July 24th, 2019, the owner contacted the Supports¿ Coordinator for a copy of the current ISP, as well as a copy of the invitation to the Individual¿s annual ISP meeting and a copy of the signature sheet from the ISP meeting on May 30th, 2019. On July 24th, 2019, the SC emailed a copy of the invitation to the invitation to the Individual¿s annual ISP meeting and a copy of the signature sheet from the ISP meeting on May 30th, 2019. Since then, these copies were printed and placed in Individual #1¿s file.On July 30th, 2019, the SC sent a copy of the current ISP and it was immediately printed and placed into Individual #1¿s ISP Binder. Upon receiving a copy of the invitation, the House Manager will scan it and upload the invitation to the company computer/flash-drive, print it, place it in the Individual¿s file and notify the CEO. The CEO will check the Individual¿s file at least two days prior to the ISP meeting to ensure a copy of the invitation has been received, scanned, uploaded, printed and placed into the Individual¿s file. Prior to any member of the ISP meeting leaving the meeting facility, the House Manager will be sure to review the accuracy and completion of the ISP Signature Form. The House Manager will then scan the ISP Signature Form, upload it to the company computer/flash-drive, print it and notify the CEO. The CEO will review the ISP Signature Form in its entirety for accuracy and completion and place it in the individual¿s file.On July 25th, 2019, the CEO and House Manager received training on the importance of obtaining, maintaining, recording and filing records of required documentation for an Individual¿s ISP records including, but not limited to the ISP, the ISP Invitation and the ISP Signature Form. The CEO and House Manager are trained in the processes involved in keeping a copy of a current ISP, as well as the processes involved in having a copy of the ISP Invitation, as well as the ISP Signature Form on file.Additionally, the House Manager and CEO will review the ISP monthly to ensure the most current ISP is on file. This review involves dissecting the ISP and reviewing the progress notes to help measure progress, notice areas of improvement or changes in behavior and to formulate new goals. The House Manager and CEO will not only continue to review progress notes, but also conduct interviews with staff members and the Individual quarterly or on an ¿as needed¿ basis in order to account for any specifics in the ISP that must be changed, added and/or updated.When any changes are submitted to an Individual¿s Supports¿ Coordinator to be updated, the House Manager and CEO will be responsible for ensuring the changes are updated in the ISP by reviewing the ISP a month after any change request was submitted to give the SC ample time to submit the requested change. Once the change is accounted for in the ISP, the CEO or House Manager must print the new ISP and apply their initials with the date and place the updated ISP in the ISP Binder at the home. Additionally, the CEO may use the company computer to access the ISP Invitation template and edit the template where it is applicable; such as the CEO¿s signature and date, along with the name of the individuals who are invited, their addresses, their relationship to the Participant as well as the date, time, location and the type of ISP meeting being conducted.
Additionally, before the CEO sends out the ISP Invitation, the House Manager must review the invitation for accuracy and completion before the CEO sends the ISP Invitation to the invitees and before it is placed in the Individual¿s file. The House Manager must initial and date the ISP Invitation to be kept on file for the Individual to ensure it was reviewed for accuracy and completion.The CEO and house manager will be trained on this process by the owner annually or on an ¿as needed¿ basis.[On 9/16/19, the required ISP documentation was contained in Individual #1'record. (AES,HSLS on 9/16/19)] |
07/24/2019
| Implemented |
| 6400.213(8) | Individual #1's record did not include copies of psychological evaluations. Individual #1's ISP, last updated 6/18/19, states that a psychological evaluation was completed for Individual #1 in 1999. | Each individual's record must include the following information: Copies of psychological evaluations, if applicable. | An ¿Initial Participant Admission Checklist¿ was designed to ensure all required documents and records are obtained and on-file with the participant. Upon admission, all docs on the checklist must be accounted for in the participant¿s file. The House Manager reviews the checklist and puts a check-mark, as well as their initials, and the date next to each characteristic on the checklist to ensure we have all of the necessary components of the checklist. The checklist includes:Each individual¿s record that includes personal information such as the name, sex, admission date, birthdate and social security number. It also includes the race, height, weight, color of hair, color of eyes and identifying marks. Additionally, the checklist involves the language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English. Moreover, it includes the religious affiliation, next of kin, as well as a current, dated photograph of the individual.
The checklist also accounts for unusual incident reports relating to the individual, physical examinations, dental examinations, dental hygiene plans, and assessments.Additionally, the bulletin includes a confirmation of the copy of the invitation to: the initial ISP meeting, the annual update meeting, and the ISP revision meeting. Moreover, the bulletin accounts for a copy of the signature sheets for: the initial ISP meeting, the annual update meeting, and the ISP revision meeting. The checklist also confirms a copy of the current ISP.It also includes documentation of ISP reviews and revisions including the following: ISP review signature sheets, recommendations to revise the ISP, ISP revisions, notices that the plan team member may decline the ISP review documentation and requests from plan team members to not receive the ISP review documentation.Content discrepancy in the ISP (the annual update or revision under) is also reviewed, along with restrictive procedure protocols and records related to the individual, copies of psychological evaluations (if applicable) and recreational and social activities provided to the individual.The checklist also includes a bulletin to confirm the Individual¿s emergency information is easily accessible at the home and includes the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. The bulletin ensures the name, address and telephone number of the individual¿s physician or source of health care are accounted for, as well as the name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.The agenda also includes a checkbox for a release of information form to be on file if applicable. After the House Manager checks off, initials, and dates all of the tasks and/or forms have been accounted for, the CEO reviews the checklist and participant¿s file to ensure all of the required documentation is present. The CEO then places their initials and date on the Initial Participant Admission Checklist. The CEO and House Manager are both aware of this admission confirmation process and received adequate training on the importance of the checklist and documentation, as well as what procedures are required with this process on July 25th 2019. This plan of correction will ensure psychological evaluations are included in an individual¿s file. The CEO and house manager will be trained on this process by the owner on a yearly or on an ¿as needed¿ basis.The SC is unaware of any psych eval conducted in 1999. Therefore she said she would change the ISP¿s date to 2007. The SC relayed the psych evaluation from 2007 and it was placed in file.The SC is unaware of any psychological evaluation conducted in 1999. The furthest one back he/she had was from 2007 & was placed in Individual #1's file.The CEO will check the ISP in one month to ensure the assignation was updated. |
07/25/2019
| Implemented |
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