| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1's funds were used to purchase items for daily living which should be purchased from room and board funds. On December 26, 2020, funds in the amount of $24.00 were used to purchase Depends; on 12/27/20, funds in the amount of $21.19 were used to purchase body wash, skin lotion and hand sanitizer. On 2/3/21, funds in the amount of $42.30 were utilized to purchase skin lotion, baby powder, body wash and Depends. On 3/9/21, funds in the amount of $16.37 were utilized to purchase baby wipes and mouthwash. | Individual funds and property shall be used for the individual's benefit. | LVHS has placed in all homes for use by all individuals (soap, shampoo, tissue, wipes, lotion, deodorant, powder, toothpaste, mouth wash). These items will be supplied by LVHS. House directors will monitor when supplies are low and request these supplies weekly, as needed |
04/23/2021
| Implemented |
| 6400.112(c) | Fire drills conducted on 8/23/20 and 8/26/20 exceeded the allotted 2 ½ minutes to evacuate the building. There was no documentation of problems that were encountered during the drill that resulted in exceeding the allotted time frame. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.101 - 6400.114 (with specific emphasis on 6400.112). RCG 112a ¿ 112i was also reviewed in the training. |
04/30/2021
| Implemented |
| 6400.112(d) | Fire drills conducted on 8/23/20 and 8/26/20 exceeded the allotted 2 ½ minutes for evacuation. Evacuation time for the 8/23/20 drill was 2 minutes(min) 38 seconds(sec) and the 8/26/20 drill 2 min 49 sec. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All LVHS house directors attended a Training Meeting on April 30, 2021 2:00pm-5:30pm (See Appendix 5). In this meeting Regulation 6400.101 - 6400.114 (with specific emphasis on 6400.112). RCG 112a ¿ 112i was also reviewed in the training. |
04/30/2021
| Implemented |
| 6400.142(f) | Individual #1's dental exam dated 3/2/21 did not include a dental hygiene plan. This area on the dental form was left blank. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Management Team met on May 7 to review Regulation 6400.142(f) and to update the LVHS dental hygiene form (See appendix 10). Moving forward this updated form must be used with all individuals during each dental checkup. Directors will ensure that the dental plan is completed by the dentist at the time of the appointment and that staff follow the dental plan. |
05/07/2021
| Implemented |
| 6400.151(a) | Staff #3 has a hire date of 9/18/20. Pre-employment/new hire physical for Staff #3 submitted for review is dated 10/16/20. Pre-employment physicals are required to be completed within 12 months prior to employment. | 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. | Provider will no longer accept other physicals completed on forms other than LVHS Pre-employment Physical forms because other forms do not always include information required by regulation. In this case, the new staff person presented his physical and it was several weeks before Provider realized it was not adequate. The employee was sent for a new physical which was conducted on 10/16/20 which was AFTER the employee had already started working. |
05/12/2021
| Implemented |
| 6400.151(c)(3) | Staff #1's physical dated 2/26/20, Staff #2's physical dated 8/26/19 and Staff #3's physical dated 10/16/20 did not include a signed statement that the staff person is free from 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. | 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. | The LVHS Pre-Employment Physical form has been updated to include the statement and a check-off verifying that the potential staff member is ¿free of communicable diseases¿, as required in 64001.51(c ) (3) |
05/12/2021
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's assessment did not include the individual's current level of performance and progress over the last 365 calendar days in the following areas: communication skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Communication. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that Communication Skills are assessed. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment did not include progress over the last 365 calendar days in the following areas: personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that Personal Adjustment is assessed. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment did not include her disability or functional or medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that disability or functional or medical limitations are assessed. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that life time medical history is included. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment did not include recommendations for specific areas of training, programming or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that recommendations for specific areas of training, programming or services is included. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment did not include progress over the last 365 calendar days in the following areas: health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that Health is assessed. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment did not include progress over the last 365 calendar days in the following areas: financial independence. | 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.
| LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that an assessment of financial independence is included. See appendix 11. |
06/30/2021
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment did not include progress over the last 365 calendar days in the following areas: managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | LVHS, as other Providers has struggled with finding and maintaining good staff. We acknowledge that we currently lack expertise in this area because provider has terminated three Program Specialist over the course of the past 3 years because of inadequate work performance. At this time, LVHS is in the process of hiring a new PS who has experience providing PS work in an ID setting. References will be carefully checked to ensure that the candidate has the required experience. An assessment template has been developed that captures all 6400.181 requirements. This template will be used in the future for all LVHS assessments to ensure that all requirements are met and to ensure that skills for Managing Personal Property are assessed. See appendix 11. |
06/30/2021
| Implemented |
| 6400.32(r)(1) | A pin key locking door knob was on the bedroom door of Individual #1. Individual #1 is able to lock the door when she is inside but the existing lock does not allow her to lock the door when not in her bedroom. No key or tool to unlock the door was available at the time of the inspection. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Provider provided inadequate locks on bedroom doors for individuals to secure their belongings from the outside of the bedroom. Provider has ordered key entry locks that are being placed on bedroom door #1 and #2. Installation will be completed by 5/21/21. Individuals will be given a bedroom key to maintain with their house key (which they already have) which will provide them with privacy when they are in their bedroom. Further, the individual will be able to secure their belongings with this key when they leave their bedroom or house. |
05/31/2021
| Implemented |
| 6400.34(a) | Rights for Individual #1 were reviewed and signed by Individual #1's legal guardian on 1/11/21. The review was not a complete review of all rights as required. Items not reviewed as outlined under 6400.32 are as follows: b, portions of c, e, f, g, portions of h, i, k, portions of m, p, q, r, s, t and u. A complete review is required to satisfy regulation. | 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. | The LVHS Management Team met on April 23, 2021 and updated the Rights Form and Policy to ensure that it aligns with 6400.34(a). See Appendix 9. All Individuals, Parents and Guardians have been provided an updated list of Rights. A new sign-off sheet regarding receipt of the updated Rights will be obtained and placed in the Individual¿s record. |
04/23/2021
| Implemented |
| 6400.46(d) | Staff #1, Staff #2 and Staff #3 received online CPR/First Aid training, however the did not complete the
in person component of the training. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Provider¿s certified CPR Instructor (Rasheda McMillan) adjusted requirements (due to the Covid-19 Pandemic) for all staff who had been previously certified under her instructorship. The adjustment included a waiver of the rescue breathing and compression demonstration portion of the test. However, all new staff (who had not been previously trained under this instructor) were required to complete the demonstration prior to working in the homes.
Provider has completed a training (Appendix 1) where all staff were required to demonstrate rescue breathing and chest compressions to pair with the online education provided by the Certified CPR instructor during the peak of the COVID-19 pandemic. |
04/30/2021
| Implemented |
| 6400.51(b)(3) | Staff #1 and Staff #3 were trained on Individual Rights as part of their orientation training however, they were not trained on the current rights. Rights training did not include rights as required under 6400.32(b),(c), (e-h), (k), (m), (p), (q-u). | The orientation must encompass the following areas: Individual rights. | Provider¿s Orientation did not cover a complete list of Individual Rights. On April 23, 2021, the Management Team updated the list to adhere to 6400.34 (a). On April 30, 2021, Provider completed a supplemental training which included a revised list of Individual Rights. (See Appendix 2). |
04/30/2021
| Implemented |
| 6400.52(c)(3) | Staff #2 was trained on Individual Rights on 10/22/20 as part of her annual training, however, she was not trained on the current rights. Rights training did not include rights as required under 6400.32(b),(c), (e-h), (k), (m), (p), (q-u). | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Provider¿s annual training did not train staff on a complete list of Individual Rights. On April 23, 2021, the Management Team updated the list to adhere to 6400.34 (a). On April 30, 2021, Provider completed a supplemental training which included a revised list of Individual Rights. (See Appendix 2). |
04/23/2021
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Toothlette Disposable Oral Swab. Brand: Toothlette. Use Swabs to clean mouth three times at 8AM, 4PM and 8PM. For oral care. There was no documentation that Individual #1 received this medication on April 2 at 4PM. | A prescription medication shall be administered as prescribed. | LVHS entered a medication error for April 2, 2021 for the missed Toothlette Disposable Oral Swab. On May 13, 2021, staff at this home were given a training review of administration of prescription medication to ensure that they are clear on medications listed on the MAR and other requirements. |
05/18/2021
| Implemented |