| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment did not contain a written summary of corrections made to violations. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The Program Specialist corrected the "Self-Inspection Tool" to include the score and the summary, see attachment #17.
Policy on the Self Assessment was developed, describing in detail the procedure for self-inspection and follow-up plan, attachment # 21.
Training conducted by the Program Specialist is documented on Attachment #22. |
01/06/2017
| Implemented |
| 6400.22(d)(2) | The home does not keep an up to date financial record for the disbursements to or for Individual #1. The financial logs always indicated a balanace of $0 with Individual #'1's signature next to the amount. He/She is given money on a regular basis that is not being logged on a financial record. | (2) Disbursements made to or for the individual.
| Program Specialist updated track changes to include a more clear financial plan for this individual. This is attachment #44. Individual has been assessed to be able to handle her own spending money and savings account. Staff does not assist individual with management of these funds. In the future, Program Specialist will pay particular attention to the individuals' financial plans. |
01/09/2017
| Implemented |
| 6400.31(b) | Individual #1's program was licensed starting on 12/1/15. Individual #1 did not sign and date a statement acknowledging the receipt of the information on their rights until 6/15/16. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Program Specialist and Director of Human Resources reviewed the Resident Right's policy. See attachment # 67. This clearly states that the resident will be educated/informed of their rights and annually thereafter. We will complete this training each January with Fire Safety Training for the individuals, attachment # 6. Attachment #67 also includes documentation that each resident has been educated of their rights for January, 2017. Staff was educated to the policy and documentation of this training is attachment # 68. |
01/09/2017
| Implemented |
| 6400.46(a) | Staff #6 was working with individuals in their homes over the past year. Staff #6 did not receive initial training in the areas of job responsibilities, daily operations of the home, policies and procedures, first aid, and fire safety before working with individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Staff #6 has been educated to the areas indicated in this violation. Documentation of training as well as Staff #6's staff physical and TB test has been included and is labeled attachment # 65. See attachment #57 for new hiring policy which will ensure that all staff are appropriately trained prior to working with individuals in the future. |
01/09/2017
| Implemented |
| 6400.46(e) | Staff #6 was working with individuals in their homes over the past year. Staff #6 did not receive training in the areas of mental retardation, principles of normalization, rights and program planning and implementation. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Staff #6 has been educated to the areas indicated in this violation. Documentation of training as well as Staff #6's staff physical and TB test has been included and is labeled attachment # 65. See attachment #57 for new hiring policy which will ensure that all staff are appropriately trained prior to working with individuals in the future. |
01/09/2017
| Implemented |
| 6400.46(f) | Staff #1 had fire safety training on 10/18/15 and not again since then. Licensing was conducted from 11/21/16-11/22/16. | 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. | Staff #1 did receive fire safety training on 9/13/16. Was unable to produce documentation during survey. It has been included as attachment #66. Moving forward, this will be offered quarterly for the company. All staff will be mandated to attend annually. |
01/09/2017
| Implemented |
| 6400.71 | The telephone numbers to the nearest police, ambulance, and poison control center were not on or near the telehphone in the staff office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The Program Specialist posted the Police-Fire-Ambulance: 911, emergency phone number poster in the staff office near the telephone, see attachment #14.
Program Specialist educated staff on "Emergency Telephone Number" policy, see attachment #15.
Attachment #16 is the documentation of the staff retraining. |
01/06/2017
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not contain individual and staff responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The program specialist updated the "Evacuation Plan" to include the distribution of duties, see attachment #12.
Staff were re-educated on the "Emergency Procedure Plan" attachment #11 and the "Evacuation Plan" attachment #12.
Documentation of retraining is Attachment #13.
Ongoing training will be conducted on hire and annually thereafter at mandatory in-service |
01/06/2017
| Implemented |
| 6400.112(a) | According to the fire drill log, Individual #1 refused to evacuate the home during the 9/19/16 fire drill. Another fire drill was not attempted and a successfull fire drill was not completed in the month of September 2016. | An unannounced fire drill shall be held at least once a month. | Program Specialist and Director of Human Resources reviewed Fire Drill policy, (attachement #5). Fire drills will be conducted unannounced on a monthly basis for each home, as mandated in the policy. Should a resident refuse to evacuate, alternative drills will be conducted within the month until such time the resident complies. |
01/09/2017
| Implemented |
| 6400.112(h) | The fire drill logs did not indicated if the individual evacuated to the designated meeting place. The fire drill log did not have a location to document if individuals met at the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The program specialist revised the policy "Fire Drills" see Attachment #5.
The fire drill log was updated to include the meeting place, see Attachment #7.
The fire drill was completed on 12/9/2016 using the revised form. |
01/06/2017
| Implemented |
| 6400.113(a) | The home was licensed on 12/1/15 and Individual #1 was living at the residence since 12/1/15. Individual #1 did not receive training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, or smoking safety procedures until 9/1/16. | 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. | Who: The program specialist and director of human resources updated the policy on Fire Safety Training, Attachment #4, to include " Upon admission and annually every January".
What: Policy was revised.
When: Current resident was re-educated on fire safety training program. The training is documented in attachment #4.
The information presented to each resident is documented on Attachments #3 & 5.
Staff retrained on the resident fire safety training plan as documented on Attachment #6. |
01/06/2017
| Implemented |
| 6400.141(c)(4) | Individual #1's 9/27/16 physical exam form did not include his/her 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. | Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Hearing and Vision screening recommendations by Primary Care Physican is documented on new form. |
01/09/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's 9/27/16 physical exam form did not include a Tuberculin skin test. There wasn't documentation that a Tuberculin skin test was ever completed for Individual #1. | 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. | Tuberculin skin test was performed prior to licensing inspection. Documentation of this test is included as attachment #60. TB test was placed on 10/18/16 and read on 10/21/16. Previous TB test was documented by staff in the Cardex (appointment list) as having been completed in March, 2015. However, signed documentation was not kept. Therefore, test was repeated on 10/18/16 to ensure compliance with regulations. Individual did not have TB test repeated at apt this January, but will have repeated prior to 10/18/18 per regulation to completed every 2 years. |
01/09/2017
| Implemented |
| 6400.141(c)(7) | Individual #1's 9/27/16 physical exam form did not include a gynecological examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Primary Care Physician's recommendations to refer to gynecology have been documented. Previously, individual had refused gynecology visit annually. |
01/09/2017
| Implemented |
| 6400.141(c)(8) | Individual #1's 9/27/16 physical exam form did not include a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual did receive a mammogram. Documentation was sent directly to physician and was not retained in her chart. Program specialist has obtained the documentation of mammogram, performed on 7/8/16, which is attachment #63. Her previous mammogram was completed on 6/25/15, which is documented in attachment #62. Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Physician's recommendation to refer to gynecology for mammograms is documented on current form. |
01/09/2017
| Implemented |
| 6400.141(c)(10) | Individual #1's 9/27/16 physical exam form did not include if their were free from communicable diseases or precausions to take if they were not free from communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Current form allows for physician to indicate if the individual is free from communicable diseases and includes questions pertaining to special precautionary instructions for individuals who are not free from communicable diseases. |
01/09/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's 9/27/16 physical exam form did not include an assessment of his/her health maintenance needs, medication regimen and the need for blood work at recommended intervals. The field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Current form now allows documentation by physician to include health maintenance needs. Direct Care staff and Program Specialist will ensure that all fields are completed or documented with N/A to ensure completion of form by physician. |
01/09/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's 9/27/16 physical exam form did not include medical information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Multiple incorrect forms were used for previous physicals. Current physical form for this individual is attachment #40. This will be utilized moving forward to ensure compliance with regulations pertaining to annual individual physicals. Current form includes the opportunity for physician to document information pertinent to individual's diagnosis. Direct Care Staff and Program Specialist will ensure that form is appropriately completed and that no spaces are left blank. |
01/09/2017
| Implemented |
| 6400.142(a) | Individual #1's record did not contain documentation that he/she had dental examinations performed by a licensed dentist. Staff #1 explained to licensing on 11/22/16 that Individual #1's dentist did not complete any dental examination forms and the agency did not inquire about obtaining dental exam records for Individual #1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | We did not have a form to demonstrate the visit. We have developed a form as referenced in previous violation summary 6400.163 (c), see attachment #37 The Dental Addendum. This individual will be seen by the dentist on 1/10/17, as he/she has now agreed to follow through with recommendations to see a dentist. |
01/09/2017
| Implemented |
| 6400.143(a) | Staff #1 indicated to BHSL licensing staff on 11/22/16 that Individual #1 refuses to attend dental examinations. The dental examination refusals and the continued attempts to train Individual #1 about the need for health care were not documented in his/her record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Program Specialist has updated the refusal of treatment plan for this individual to include which treatment(s) are being refused, what is the expressed reasoning for refusal of treatment, frequency of education and proposed action plan to encourage individual to comply with treatment recommendations. Individual #1 was educated on 1/4/17 pertaining to the importance of dental care. She subsequently agreed to treatment and will be seen on 1/10/17 for her annual dental visit. Attachment #59 is included for this individual to demonstrate usage of refusal of treatment plan. |
01/09/2017
| Implemented |
| 6400.145(3) | The written emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | WHO: The program specialist and director of human resources updated the policy on the emergency medical plan, attachment #1.
What: The emergency medical plan was revised to include the link between the supervisor and the team leader. The team leader is now directed to call the supervisor on call in the event of a medical emergency
When and How: All staff were retrained on the revisions of the policy, see Attachment #2. Moving forward the emergency medical plan with new provision will be addressed in new employee orientation and part of our annual mandatory in-service training.
Dates: 1/3/2017 |
01/06/2017
| Implemented |
| 6400.151(a) | Staff #3's date of hire was 6/13/16 and he/she did not have his/her physical completed until 6/22/16. | 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. | Program Specialist and Director of Human Resources created a specific policy for Hiring Procedures for Direct Care Staff, which clearly outlines a procedure to ensure that physical is completed prior to hire date. This policy can be found as attachment #57. It clearly outlines all qualifications necessary for Direct Care Staff workers and has been derived from 6400 regulations to ensure compliance. The hiring process now includes a 2-interview process. At first interview, if an applicant is deemed initally qualified, he/she will be provided with the Employee Physical Form and instructed to have completed prior to a second interview. During the interim between first and second interviews, Human Resources will complete the request for criminal background check. At second interview, providing that physical form is complete and all other necessary requirements are met, a job offer will be extended and training will begin. Included is the job offer, physical form, and TB test obtained from our most recent hire to demonstrate utilization of the new hiring policy (attachment # 58). |
01/09/2017
| Implemented |
| 6400.151(c)(2) | Staff #3's date of hire was 6/13/16 and he/she did not have a tuberculin skin test completed until 6/24/16. | 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. | Program Specialist and Director of Human Resources created a specific policy for Hiring Procedures for Direct Care Staff, which clearly outlines a procedure to ensure that physical is completed prior to hire date. This policy can be found as attachment #57. It clearly outlines all qualifications necessary for Direct Care Staff workers and has been derived from 6400 regulations to ensure compliance. The hiring process now includes a 2-interview process. At first interview, if an applicant is deemed initally qualified, he/she will be provided with the Employee Physical Form and instructed to have completed prior to a second interview. During the interim between first and second interviews, Human Resources will complete the request for criminal background check. At a second interview, providing that physical form is complete and all other necessary requirements are met, a job offer will be extended and training will begin. Included are the job offer, physical form, and TB test obtained from our most recent hire to demonstrate utilization of the new hiring policy (attachment # 58). |
01/09/2017
| Implemented |
| 6400.151(c)(3) | Staff #3's 6/22/16 physical examination form and Staff #4's 11/17/15 physical examination form did not indicate if they were free from communicable diseases. Neither Staff's record indicated if they were free from communicable diseases either. | 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. | Program Specialist and Director of Human Resources revised previous staff physical form to include information pertaining to the applicant's communicable disease status. This form has been included as attachment #58 for our most recent hire for review. This will be the form used for all future hires to ensure compliance. |
01/09/2017
| Implemented |
| 6400.163(c) | Individual #1 was prescribed Fluphenazine and Quetiapine Fumarate for Mood Disorder and Clonazepam and Lorazepam for anxiety, His/Her 11/15/16, 10/31/16, 8/8/16, 5/5/16, and 1/19/16 medication review did not review all psychotropic medication dosages or the reason they are prescribed. Individual #1 had a medication review completed on 1/19/16 and not again until 5/5/16, outside of the 3 month time frame. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Program Specialist has reorganized the chart to separate the chart into a more user-friendly version as suggested in the survey. The new index for the charts is attachment #34. A new form was developed, " The psychiatry addendum" Attachment #37, it includes the psychotropic medication and provides space for the physician to document need to continue the medication. This form was put into place and utilized specifically with this individual on 11/29/16 (attachment #56) and also on 12/22/16 (attachment #55). The staff was trained on the use of the new form for specialty appt's , see attachment #37. |
01/09/2017
| Implemented |
| 6400.164(a) | The medication logs for Individual #1 for the past year contained numerous instances where staff did not initial the medication log after administration of medication and a time of administration was not indicated. Staff did not initial after administration of Novolog Flex Pen Insulin at 8pm on 10/31/16, 10/24-29/16, 10/18-22/16, 10/13-15/16, 9/30/16, 9/28/16, 9/13-19/16, 9/1-11/16, 8/18-31/16, 8/8-16/16, and 8/5-8/6/16. Staff did not initial after administration of Novolog at 4pm on 10/31/16, 10/26-27/16, 10/22/16, 10/19/16, 10/13/16, 9/28-29/16, 9/15-19/16, 9/12/16, 9/10/16, 9/1-8/16, 8/28-31/16, 8/26/16, 8/20-23/16, 8/12-18/16, 8/9-10/16, and 8/6-7/16. Staff initials and time of administration was not included on Individual #1's medication log for administration of Acetaminophen on 7/31/16. There was a sticky note on this medication log to have Staff #5 initial the 2pm administration of Acetaminophen. The time of administration for Nystatin was not indicated on the 4/3/16, 4/16/16, 4/22/16, and 4/24/16 medication log for Individual #1. The 4/26/16 medication record did not include staff initials for administration of artificial tears, checking his/her blood sugar levels, or administering insulin. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Staff in this home was retrained to medication administration records documentation (attachment #53). Medication administration record for this individual for Dec, 2016 is included as attachment #54 to demonstrate staff's understanding of proper MAR documentation. All staff will continue to receive quarterly MAR reviews and Medication administration observations to ensure adequate understanding of correct procedure for medication administration and accurate MAR documentation. Upon discovery of any inadequate understanding of correct procedure or documentation, staff will be remediated accordingly. All other homes were assessed after inspection and all other MARs were appropriately filled out and medication administration was documented appropriately. Remediation was only performed for staff working at this individual's home. |
01/09/2017
| Implemented |
| 6400.181(e)(7) | Individual #1's 9/12/16 assessment did not include their knowledge of heat sources and ability to sense and move away quickly from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. |
01/06/2017
| Implemented |
| 6400.181(e)(10) | Individual #1's 9/12/16 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Information pertaining to Individual's lifetime medical history has been included. Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. |
01/09/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 9/12/16 assessment did not include their progress and current level in motor and communication skills over the last 365 calendar days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Information pertaining to the progress in the areas of motor and communication over the past 365 days has been addressed. Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. |
01/09/2017
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 9/12/16 assessment did not include their progress and current level in financial independence over the last 365 calendar days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Track Changes to update Financial plan has been submitted (attachment #44). This information has been included in revised annual (attachment #52). Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. |
01/09/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's 9/12/16 assessment did not include their progress and current level in community-integration over the last 365 calendar days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Community outings for the last 365 calendar days has been included, in addition to a summary of her progress in the area of community integration over the past 365 calendar days has been included. Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. |
01/09/2017
| Implemented |
| 6400.181(f) | Individual #1's 9/12/16 assessment was not sent to their behaivor support specialist. | (f) 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 under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Program Specialist has revised Annual Assessment from 9/12/16. Format has been changed to allow more information and detail to be included in the assessment. Updated Annual can be found as attachment #52. Previous Annual is also available for comparison as attachment #48. Program Specialist will move forward with format seen in Attachment #52. See attachment #52 for documentation that the revised annual was sent to Individual's behavior specialist. |
01/09/2017
| Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan (ISP) did not include a protocol to address his/her social, emotional, and environmental needs. His/Her ISP did contain his/her behavior support plan, however his/her behavior support plan did not include his/her symptoms of delusions and hearing voices that have been occuring since living at her residence. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Program Specialist has submitted track changes to Support's Coordinator (attachment #44) that addresses individual's Social, Emotional and Environmental Plan, which includes the individual's needs and the actions required to meet those needs. Delusional behavior was also address in the same attachment in psychosocial section. |
01/06/2017
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | Program Specialist included Potential to advance in vocational programming in track changes (attachment #44) to Support's Coordinator. This will be included in ISPs moving forward. |
01/06/2017
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) did not include their potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| Program Specialist included the individual's potential to advance in competitive employment in track changes (attachment #44). This will be included in ISPs in the future. |
01/06/2017
| Implemented |
| 6400.184(c) | Individual #1's record did not contain documentation for individuals that attended his/her Individual Support Plan (ISP) meeting. The record did not contain a meeting participant signature sheet with signatures of those in attendance or the date of the meeting. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | Program Specialist obtained ISP sign in sheet for meetings held on 1/12/17 (attachment #50) and 1/12/16 (attachment 51). To ensure compliance in the future, Program Specialist will ensure that a copy of the sign in sheet is obtained prior to end of ISP meeting. |
01/06/2017
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) indicated that he/she required staff to perform checks every 2 hours at night. There was no documentation that this occurred. His/Her ISP indicated that staff were to contact their supervisor if Individual #1's weight fluxuates less than 3 pounds in a 24 hour period. Individual #1's weight fluxuated less than 3 pounds on 10 different occasions just in the month of November 2016 so far. There was no documentation that a supervisor at Eagle Valley was notified. The program specialist indicated to licensing on 11/22/16 that a supervisor was not notified in any of those instances. Individual #1's ISP indicated that he/she is not able to manage his/her own finances independently. Individual #1's financial logs for the past year indicated that he/she has been given monetary amounts up to $65.00 to handle independently on multiple occasions. | The ISP shall be implemented as written. | See paper file. |
01/09/2017
| Implemented |
| 6400.186(a) | Individual #1's Individual Support Plan (ISP) reviews were not completed within a 3 month time frame. They were completed on 9/2/16, 5/18/16, and 2/1/16. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Program Specialist created a new schedule for ISP quarterlies based on annual review date. The plan was emailed to the surveyor for approval, see attachment #26 on November 28th. The new schedule of quarterlies reviews was implemented immediately after receiving confirmation on the appropriateness of the schedule. This individual's quarterly review was completed on December 2 for the time frame of 9/2-12/2. (attachment #45). Subsequent quarterly was completed for Dec 2- Jan 12 to indicate adherence to the time frame. (attachment #46). |
01/06/2017
| Implemented |
| 6400.186(b) | Individual #'1's Indivdiual Support Plan (ISP) reviews did not contain a written date. The date was prepopulated on the ISP review. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Program Specialist will not pre-populate the date on the ISP reviews. See attachment #45. The CEO and Program Specialist reviewed the regulation and policy to ensure our compliance with the standard. Attachment 28a is a portion of the "Program" policy that reviews the requirements for quarterly reviews, including that the review will be signed/dated by Program Specialist and Individual upon review. |
01/06/2017
| Implemented |
| 6400.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews did not review his/her "supervision" and "managing stress" outcomes. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Program Specialist has re-written Quarterly Review, paying particular attention to the areas of "supervision" and ensuring that "managing my stress" outcomes are appropriately documented. See attachments #45 and #46. To eradicate violation in the future, Program Specialist now has a better understanding of the level of detail and information required in the reviews. |
01/06/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews did not review his/her behavoir support plan, social emotional and enviornmental plan, and community outings. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Program Specialist has re-written the review to include information pertinent to individual's behavior support plan, social, emotional and environmental plan and also includes a comprehensive list of community outings during the time of review. See attachment #46. For future reviews, Program Specialist will utilize consistent layout of information to ensure that all pertinent information is included in each review. |
01/06/2017
| Implemented |
| 6400.186(d) | Individual #1's Individual Support Plan (ISP) reviews completed on 9/2/16 and 2/1/16 were not sent to any team members. The 5/18/16 ISP review was not sent to his/her behavior support person. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Review submitted in February was sent to Support's Coordinator only. (See attachment # 47) The Review sent on 9/2 was omitted in error when sent to Support's Coordinator, but Annual Review was sent to Support's Coordinator on 9/12 (see attachment #48). Quarterly review on Dec 2 was sent to all team members See attachment #45. The review completed on January 5 was sent to every team member. Program Specialist has created a list that includes the names and contact information for each team member to ensure that all team members receive all ISP documentation. |
01/06/2017
| Implemented |
| 6400.186(e) | Individual #1's team members included a supports corrdinator, day program, behavior support person, and a family member. The option to decline the Individual Support Plan (ISP) review documentation was only offered to Individual #1's supports coordinator on 8/25/16. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Documentation did not support that all team members were sent the option to decline. Option to decline was, in fact, sent to Support's Coordinator and brother on 8/25/16, (attachment #49) Behavior Supports person was omitted at that time. All members were re-notified of their option to decline on 12/2/16 when emailed the quarterly (see attachment #45). For future options to decline, Program Specialist will ensure that appropriate documentation of the recipient is maintained. |
01/06/2017
| Implemented |
| 6400.195(a) | Individual #1's restrictive procedure plan was approved to be implemented by the restrictive procedure review committee on 3/2/16. However, the agency implemented the restrictive procedure plan on 2/3/16, before it was approved by the committee. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| Program Specialist has been re-educated to appropriate restrictive procedures policy (see attachment #41). Program Specialist, additionally, sought out additional training in Behavior Support and Crisis Intervention (see attachment #42). In the future, Program Specialist will review restrictive procedures prior to implementation of a new restrictive plan to ensure compliance with regulations. |
01/06/2017
| Implemented |
| 6400.195(d) | The chairperson of the restrictive procedure review committee did not sign and date the restrictive procedure plan review completed on 5/4/16 and 3/2/16. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Program Specialist requested HRC chairperson sign plan review sheet for meetings where signature was missing (see attachment #43). In the future, Program Specialist will maintain HRC review sheet signature page at every meeting and will be retained in the resident's chart. |
01/06/2017
| Implemented |
| 6400.195(e)(8) | The restrictive procedure plan did not include the name of the staff person responsible for monitoring and documenting progress with the plan. | The restrictive procedure plan shall include: The name of the staff person responsible for monitoring and documenting progress with the plan.
| Program Specialist submitted track changes to Supports Coordinator, including with behavior plan documentation that includes the name of the staff person responsible for monitoring and documenting progress with the plan. That individual is the Program Specialist. This information will now be included in the ISP with the behavior plan information. Attachment #44. (highlighted area). In the future, Program Specialist will ensure that this information is included in all future restrictive plans. |
01/06/2017
| Implemented |
| 6400.213(9) | A current copy of Individual #1's Indiividual Support Plan (ISP) was not in his/her record. The ISP in the record was last updated on 8/9/16. Since then, the ISP has been updted to include many medications that he/she is taking. Those medications include Metformin 1000mg, Ativan 1mg twice daily as needed, QC A10 as needed, Polyethylene Glycol, Rulox Suspension as needed, and Cough Syrup as needed. | Each individual's record must include the following information: A copy of the current ISP. | The Program Specialist has reorganized the chart to separate the chart into a more user-friendly version as suggested in the survey, that includes the ISP and ISP documentation. The new index for the charts is attachment #34. Additionally, to prevent this violation in the future, Program Specialist has implemented a weekly check of HCSIS, which is documented and kept with ISP documentation to ensure most current ISP is in the chart. See attachment #38. Program Specialist will use weekly checks to be alerted to changes made to the ISP as well as to follow up with requested changes to the ISP. |
01/06/2017
| Implemented |
| 6400.213(11) | Individual #'1 1/29/16 physical examination form indicated that he/she should follow a "heart healthy" diet. Other forms within the 1/29/16 physical exam form documents also indicated he/she did not have a specific diet, and also "no added salt/diabetic diet." His/Her 9/27/16 physical exam forms indicated his/her diet was "none" and "consistent carbs." Individual #1's 9/27/16 physical indicated he/she did not have allergies. However his/her Individual Support Plan (ISP) indicated he/she was allergic to Aspirin. Individual #1's facesheet in his/her record indicated he/she still lived at the Eagle Valley Personal Care home in room B13. He/she actually lives at 303 Depot Street, Milesburg, PA. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Multiple incorrect physical forms were used for 2016's Annual Physical for this individual. Program Specialist has implemented correct physical form (Attachment #40). Additionally, Program Specialist has reviewed this individual's actual diet recommendation, which is NAS, diabetic. Information has been updated in documentation system (See attachment #39). In the future, Program Specialist will utilize only the correct physical form. |
01/06/2017
| Implemented |
| Article X.1007 | Eagle Valley Inc. is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #2, #3, #4 were hired on 7/26/16, 6/13/16, 5/3/16 respectively; the criminal history checks were requested on 7/27/16, 6/15/16, 5/5/16 respectively. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Program Specialist and Human Resources Director have developed a policy to ensure that new hires meet all necessary regulations prior to hire date. See attachment #57. All new hires will have a criminal background check requested no later than between the first and second interviews, prior to hire. See attachment #58, which includes our newest hire's background check. |
01/09/2017
| Implemented |