| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(b) | Located in Room #5 in the bottom drawer of the locked 2-drawer filing cabinet where individuals store their belongings was a 24 fl. oz. white and blue spray bottle with a blue manufactured label of "Duracare Ultimate Sprayer", but the bottle had in black marker "409 Cleaner" written on it. Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | Regulation 2380.53(b) was reviewed with staff during a staff meeting on 8/2/24. A line was added to the fire drill form to check program rooms for poisons and to ensure all are in original containers after every drill. |
08/01/2024
| Implemented |
| 2380.59(b) | The water temperature measured 126.9°F in the Men's/Boy's lavatory at the time of the inspection which exceeds the limit of 120 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Water temperature was turned down immediately once made aware of the temp being 120 degrees. Water temperature will be checked after each fire drill. There was a section added to the fire drill paper to write the temperature down once it is checked and corrective action if needed. |
08/02/2024
| Implemented |
| 2380.91(a) | Individual #1's fire safety training dated 3/7/24 that was in Individual #1's record did not document a name therefore there is no way of knowing that individual #1 was trained on fire safety. Individual #2 had annual fire safety training on 1/31/23, and there is no record or documentation that they have had the training since. (Repeat Violation 6/30/23) | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility. | All fire safety training will be done with individuals yearly with the individual rights. This will be done by the Program Specialist. Reminders will be set on calendar to send out a month prior for guardians/POA to have time to sign and return. |
08/07/2024
| Implemented |
| 2380.111(a) | Individual #4 was admitted on 3/11/2024 and there was no physical examination in the individual's record. (Repeat Violation 6/30/23) | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical was done prior to admission. It was misplaced and a copy was emailed to Executive Director the same day. Original completion date of physical was 7/31/23. It was filed in the individual's program book. |
07/29/2024
| Implemented |
| 2380.111(c)(4) | Individual #1's physical examination dated 2/8/24 and Individual #2's physical dated 9/6/23 did not include a vision and hearing screening as this section of their physical examination was left blank. (Repeat Violation 6/30/23) | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Physical forms will be turned into the Program Specialist once completed and reviewed. A second review will be completed by Executive Director to ensure completeness. Any missing sections will be addressed with the family/group home and the physical sent back to be corrected. |
07/22/2024
| Implemented |
| 2380.111(c)(5) | Individual #4 was admitted on 3/11/2024 and there was no tuberculin testing in the individual's record. (Repeat Violation 6/30/23) | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Physical was done prior to admission including TB test. It was misplaced and a copy was emailed to Executive Director the same day. Original completion date of physical was 7/31/23. It was filed in the individual's program book. |
06/25/2024
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination dated 2/8/24 did not include medical information pertinent to diagnosis in case of emergency as this section was left blank on the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Physical forms will be turned into the Program Specialist once completed and reviewed. A second review will be completed by Executive Director to ensure completeness. Any missing sections will be addressed with the family/group home and the physical sent back to be corrected. |
07/22/2024
| Implemented |
| 2380.173(1)(v) | There was no dated, current photograph in the record for Individual #1, Individual #2 and Individual #4. The photograph in the record for Individual #3 was not dated. (Repeat Violation 6/30/23) | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | All face sheets were updated and pictures added by Program Specialist. |
07/30/2024
| Implemented |
| 2380.173(4) | Individual #1's record did not include an assessment. | Each individual¿s record must include the following information: Assessments as required under § 2380.181 (relating to assessment). | Assessment was completed and filed in the book. Going forward a tracking sheet has been developed and a Program Specialist has been hired who would be responsible for completing and updating the assessments. |
07/17/2024
| Implemented |
| 2380.181(a) | Individual #1's date of admission is 3/7/24, and there was no record or documentation of a 60-day assessment for Individual #1 in their record. Individual #2 had an annual assessment on 9/9/21 and their next on occurred on 9/8/23. Individual #2 did not have an annual assessment in 2022. Individual #4 was admitted on 3/11/2024 and an initial assessment had not been completed within sixty days of admission. (Repeat Violation 6/30/23) | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Assessment was completed and filed in the book. Going forward a tracking sheet has been developed and a Program Specialist has been hired who would be responsible for completing and updating the assessments. |
07/17/2024
| Implemented |
| 2380.21(u) | Individual #2 was informed of their individual rights on 1/9/23, and there is no record or documentation that they have been informed since. (Repeat Violation 6/30/23)
Individuals #1, #3 and #4 were informed of rights but the individual rights statement reviewed with the individuals was missing several individual rights required by Chapter 2380.21. Rights that were not included:
21c -- Individuals cannot be reprimanded, punished or retaliated against for exercising their rights.
21d -- A court's written order that restricts an individual's rights shall be followed.
21e -- A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order.
21f -- An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-makin in accordance with the court order.
21h -- An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age.
21k -- An individual shall be treated with dignity (respect is included in provider's rights statement).
21l -- An individual has the right to make choices and accept risks.
21m -- An individual has the right to refuse to participate in activities and services.
21q -- An individual has the right to participate in the development and implementation of the individual plan.
21r -- An individual's rights shall be exercised so that another individual's rights are not violated.
21t -- An individual's rights may only be modified in accordance with 2380.185 (relating to the content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The facility 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 facility and annually thereafter. | All fire safety training will be done with individuals yearly with the individual rights. This will be done by the Program Specialist. Reminders will be set on calendar to send out a month prior for guardians/POA to have time to sign and return. |
07/22/2024
| Implemented |
| 2380.21(v) | Individual #'1's Individual rights dated 3/7/24 were not signed by Individual #1 the document/form only had a staff signature on it. | The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | All fire safety training will be done with individuals yearly with the individual rights. This will be done by the Program Specialist. Reminders will be set on calendar to send out a month prior for guardians/POA to have time to sign and return. |
07/22/2024
| Implemented |
| 2380.36(b) | There was no documentation in Staff #2's training file to show that they completed fire safety training during the required time frame. A syllabus was provided that stated that the staff completed fire safety training during training year 7/01/2022 to 6/30/2023 but the date of training and the length of the training was not documented. Without documentation of the date of training, it is not possible to determine if fire safety training was completed within 365 days of the previous fire safety training, as required by regulation. (Repeat Violation 6/30/23) | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Initial/annual training sheet had been implemented for training year 2023-2024 and forward. It documents each training and the amount of time for each training. Sign in sheets and training sheet will be maintained in the Adult Program office. Fire safety is done as an entire school in October during fire safety week..A separate signature sheet will be completed and signed by the trainer for the adult program. |
07/17/2024
| Implemented |
| 2380.36(c) | Staff #2 completed recertification in First Aid and CPR late. The previous training expired on 8/23/2021 but was not recertified until 8/24/2023. (Repeat Violation 6/30/23) | There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification. | Moving forward CPR training will be done yearly instead of bi-yearly. Group A will be done in 2024 during in-service days in August. Group B will be done in 2025 during in-service days. This will ensure that there is always enough staff CPR trained within the program. |
08/22/2024
| Implemented |
| 2380.37(a) | Staff #1's agency orientation training documentation form did not include the length of the trainings on the form. The training records for Staff #2 did not show dates completed or length of trainings for required trainings 39c1, 39c2, 39c4 and 39c5. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Initial/annual training sheet had been implemented for training year 2023-2024 and forward. It documents each training and the amount of time for each training. Sign in sheets and training sheet will be maintained in the Adult Program office. |
07/17/2024
| Implemented |
| 2380.39(a)(1) | Staff #2 did not complete 24 hours of training year during training year 7/01/2022 to 6/30/2023. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Initial/annual training sheet had been implemented for training year 2023-2024 and forward. It documents each training and the amount of time for each training. Sign in sheets and training sheet will be maintained in the Adult Program office. Training hours will be reviewed at staff meetings held the first Friday of every other month. To be done in August, October, December, February, April, and June. |
08/02/2024
| Implemented |
| 2380.39(c)(6) | Staff #2 did not complete training in implementing the individual plan during training year 7/01/2022 to 6/30/2023. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All staff were retrained on all ISP's and a sign in sheet completed for each individual in the program. Program Specialist will ensure upon admission, plan updates, and new plans that the plans are reviewed by each staff. |
08/02/2024
| Implemented |
| 2380.125(f) | Individual #3 takes medication to treat the symptoms of a diagnosed psychiatric illness and there was not a written protocol as part of the individual plan to address the social, emotional and environmental needs (SEEN Plan) of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A SEEN plan will be written and implemented by Program Specialist. SEEN plan will be reviewed at quarterly meeting on 8/8/2024 with the plan team. |
08/08/2024
| Implemented |
| 2380.129(a) | Staff #2 was recertified to administer medications on 10/10/2023 but the 2nd observation was completed late, and there was no documentation that the required remediation was completed. Staff #2 has not complied with the Department-approved medication administration course renewal requirements.
Staff #3 was recertified to administer medications on 3/20/2024, which was past the recertification date of 3/15/2024 (date of initial certification was 3/15/2023). Additionally, the medication administration observations were completed on 12/21/2023 and 3/20/2024 which was not in the required timeframe of one observation every six months for a total of two observations completed before the renewal anniversary date of 3/15/2024. There was no documentation that remediations were completed. Staff #3 has not complied with the Department-approved medication administration course renewal requirements. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Previously another program's medication trainer was used to train and do all med passes and MAR reviews. Due to the travel time and responsibilities at her home program it was not always possible to get to St Joseph Center when necessary. Executive Director is now the medication trainer for the St Joseph Center Adult Program. Now that there is a medication trainer on site this will not be an issue. Staff #3 was on maternity leave during a time when a medication pass was due. It was completed upon return from maternity leave. |
07/17/2024
| Implemented |
| 2380.173(1)(i) | Individual #2's record did not include their admission date as this section was left blank on the form in the record. | The name, sex, admission date, birthdate and Social Security number. | All face sheets were updated and pictures added by Program Specialist. |
07/30/2024
| Implemented |