| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(g) | A video recorder was mounted on the wall in the living room directed toward the front door. | 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. | The mounted video recorder lens has been covered and recorder is no longer recording.
Ongoing, ALC will only have operable video recorders on the outside premises of the home. [On 6/23/17, the video recorder was no longer mounted on the wall in the living room. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.70 | The home did not have an operable, noncoin-operated telephone with an outside line. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| To correct non compliance of this area, ALC has installed an operable, non-coin operated "cord" telephone with an outside line that is easily accessible to individuals and staff.
Ongoing, ALC will only install operable, non-coin operated "cord" telephone with an outside line that is easily accessible to individuals and staff. [On 6/23/17, there was an operable, noncoin-operated telephone with an outside line accessible to the individuals and staff. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.110(b) | The nearest operable automatic smoke detector to bedroom #1 was 18 feet 6 inches from the doorway. The nearest operable automatic smoke detector to bedroom #2 was 22 feet 2 inches from the doorway. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | in order to correct non- compliance of this area, Smoke detectors have been moved so that they are within 15 feet of bedroom doors of individual #1 and #2. Ongoing, ALC will use a measuring tape to ensure smoke detectors are within 15 ft of doorways of staff and individual bedrooms; when installing smoke detectors. [Smoke detectors have placed approximately 3 feet from bedroom #1 and 9 feet from bedroom #2. (AS 7/5/17)]] |
05/05/2017
| Implemented |
| 6400.112(c) | The written fire drill record for the fire drill held on 12/1/16 recorded the amount of time it took for evacuation as 92 minutes. | 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. | Fire Drill log was an error. It should have been 92 secs, NOT minutes. Ongoing, staff will ensure to complete fire drill logs with thorough detail, and reviewing them upon completion for any identified errors. [Fire drill records for April, May and June 2017 were completed correctly. At least monthly for 6 months, the CEO or designee shall review all fire drill records to ensure accurate completion and fire drill are completed as required. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.141(c)(6) | The most recent Tuberculin skin testing was completed 9/12/14 for Individual #1, admission date 12/1/16. | 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. | in order to correct this area of non compliance, ALC will schedule a TB test for Individual #1.
Ongoing ALC will ensure to avoid recurrence of violation by ensuring TB test is completed the same day as physical. This will ensure that TB test is continuously current every 2 years. [On June 5, 2017 Individual #1 obtain a Tuberculin skin testing. Immediately and upon completion, the CEO shall review all completed physical examinations to ensure all required information is included and there are not any required areas left blank. (AS 7/5/17)] |
05/12/2017
| Implemented |
| 6400.141(c)(9) | Individual #1, date of birth 5/4/74 does not had a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | ALC has developed a "statement of medical exemption" form. Individual #1 doctor stated he has deferred the prostate exam until age 50 (the normal requirement). ALC has a completed "statement of medical exemption" form from Individual's #1 doctor stated he is not to get a prostate exam until age 50. The statement is signed, dated, and stamped from the doctor. Ongoing, "statement of medical exemption" forms will be completed by appropriate doctor if they recommend an exemption for stated exams in regards to individuals. [Individual #1's doctor signed and dated letter stating Individual #1 does not require a prostate examination until 50 years of age. Upon completion, the CEO or designee shall review all individuals; physical examinations to ensure all required information is included and there are not any area of required information left blank. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(a) | Individual #1's assessment does not include a date of completion; therefore compliance could not be measured. | 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. | in order to correct this area of non compliance, program specialist will complete new assessment which will include a date of completion and will be sign and dated by both the program specialist and individual. This assessment will be sent to SC, and complete plan team including behavior support and day program. Ongoing, in order to alleviate recurrence of this violation, ALC will include, date of completion and sign and date by all parties, on the process to complete assessments checklist. This checklist will be used when completing current and future assessments for all individuals [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(d) | Individual #1's assessment was not dated by a program specialist. | The program specialist shall sign and date the assessment. | in order to correct this area of non compliance, program specialist will complete new assessment which will include a date of completion and will be sign and dated by both the program specialist and individual. This assessment will be sent to SC, and complete plan team including behavior support and day program. Ongoing, in order to alleviate recurrence of this violation, ALC will include, date of completion and sign and date by all parties, on the process to complete assessments checklist. This checklist will be used when completing current and future assessments for all individuals [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment does not include functional strengths, needs and preferences of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the functional strengths, needs and preferences of the individuals. This page was added and completed to the current Assessments of individual #1. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the functional strengths, needs and preferences of the individual. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/12/2017
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment does not include likes, dislikes and interests of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the likes, dislikes and interest of the individuals. This page was added and completed to the current Assessments of individual #1.
Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the likes, dislikes and interest of the individual. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/12/2017
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment does not include documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include Documentation of the individual's disability, including functional and medical limitations of the individual. This page was added and completed to the current Assessments of individual #1. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include Documentation of the individual's disability, including functional and medical limitations of the individual. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include A lifetime medical history. of the individual. This page was added and completed to the current Assessments of individual #1. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include A lifetime medical history of the individual. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment does not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include Recommendations for specific areas of training, programming and services. This page was added and completed to the current Assessments of individual #1. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include Recommendations for specific areas of training, programming and services. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment does not include current level in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the individual's progress over the last 365 calendar days and current level in Socialization. This page was added and completed to the current Assessments of individual #1. Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the individual's progress over the last 365 calendar days and current level in Socialization. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment does not include the current level in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | In order to correct this area of non- compliance, ALC has developed and additional page for current completed assessments to include the individual's progress over the last 365 calendar days and current level in recreation. This page was added and completed to the current Assessments of individual #1 Ongoing, to alleviate the area of non compliance, ALC has revised the current Assessments used to include the individual's progress over the last 365 calendar days and current level in recreation. These new assessments will be used for all current and future individuals. [On 6/29/17, the program specialist completed the assessment for Individual #1 and signed and dated upon completion. A new assessment form has been developed. For at least one year, upon completion by the program specialist, the CEO shall review all individuals' assessments to ensure all individuals' assessments are completed timely and include all required information. Documentation of reviews by the CEO shall be kept. (AS 7/5/17)] |
05/12/2017
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment to the SC and plan team members, including the behavior supports and the day program. | (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).
| Revised assessments of Individual #1 will be sent to SC, and plan team members including behavior supports and day program upon completion. Ongoing, to alleviate the recurrence of this area of non- compliance, ALC has developed an " Assessment Checklist" which includes the process/ info of the completion of the assessment, including sending assessment to corresponding team, and 30 days prior to ISP meeting, Once ALC receives the ISP invite, program specialist will send completed Assessment s to SC, Plan team including Behavior supports and day program. [On 6/30/17, the updated assessment for Individual #1 was provided to the plan team members including behavior supports and the day program and documentation of the correspondence is kept in the record. At least quarterly for 1 year, the CEO shall review the correspondence documentation and aforementioned check list to ensure the program specialist provide all individuals' assessments to the plan team member, timely. Documentation of the reviews by the CEO shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.186(a) | The program specialist did not complete an ISP review for Individual #1 from 1/1/17 through 3/31/17. | 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. | In order to address this area of non compliance, the Program Specialist, Venetta Greenhowe, will complete the ISP review for individual #1 , for the period of 1/1/17- 3/31/17 (since it just past).
Ongoing, to avoid re-occurrence of non compliance of this area, ALC has developed a "3 Month ISP Review Schedule, effective current quarter: (2nd: 4/1/17- 6/30/17.) and so on, to ensure all Quarterly ISP Reviews are completed in a timely matter. All individuals enrolled at ALC will follow this schedule to ensure non- compliance never occurs again. [A "3 month ISP review schedule" has been developed for the program specialist to utilize. Individual #1's 3 month ISP review from 1/1/17 through 3/31/17 was completed and sent to the team on 4/6/17. At least quarterly for 1 year, the CEO shall review all individuals' ISP reviews to ensure timely completion by the program specialist. Documentation of the CEO reviews shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include color of hair, color of eyes, identifying marks, religious affiliation and a current, dated photograph. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) 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. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Photograph was completed, it just was not in the record. ALC has placed the current dated photograph, along with Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) 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. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin in the individual's record. Ongoing, ALC will ensure the photograph and information is included in all individuals files. The information photograph has been added to the :individual file checklist to ensure it is included in all current and future individuals of ALC [Individual #1's record was updated to include color of hair, color of eyes, identifying marks, religious affiliation and a current, dated photograph. Immediately, and at least biannually, the CEO or designee shall review all individuals' record to ensure all required personal information is included. Documentation of reviews shall be kept. (AS 7/5/17)] |
05/05/2017
| Implemented |