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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(a) | There were packets of Motrin in the first aid kit. | Prescription medications shall only be used by the individual for whom the medication was prescribed. | The Motrin was immediately removed from the first aid kit and appropriately disposed (attachment #21). To ensure compliance that prescription medications are used only by the individual for whom the medication was prescribed, CHS Co-Directors sent a memo to program managers, instructing them to immediately check all current first aid kits to ensure that no Motrin or other medication was in the kits, and to always check newly purchased first aid kits to ensure that Motrin or other medication was not packaged in the kits and to appropriately disposed of any such medication if found (attachment #22). Going forward, program managers will visit all their sites at least weekly, and check the contents of the first aid kits (attachment #23), which will be submitted to co-directors biweekly. Any issues of noncompliance will be immediately addressed. |
03/29/2019
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | Three lights in the kitchen were not working (one was missing a bulb). | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Electrician was contracted to complete wiring repair to the lights. All lights were outfitted with bulbs and are in working order (attachments # 4). To ensure compliance that all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes shall be lighted to assure safety and to avoid accidents , the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
12/30/2016
| Implemented |
| 6400.67(b) | The deck at the rear of the home had raised nails in the floorboards. The deck at the rear of the home had loose and splintering handrails. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Deck floorboard was repaired (attachment # 5). Deck rail was repaired (attachment #6). To ensure compliance that clean and sanitary conditions as well as furniture and equipment shall be nonhazardous, clean, and sturdy and well maintained in the home, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
12/05/2016
| Implemented |
| 6400.161(e) | Thorazine 25mg. tablets were found in Individual #1's medication box, but the medication was not listed on the individual's current MAR. | Discontinued prescription medications shall be disposed of in a safe manner. | Discontinued medication was immediately removed from Individual #1's medication box and returned to the nurse for proper disposal. To ensure compliance that discontinued prescription medications shall be disposed of in a safe manner, program directors instructed nursing personnel to be involved in all discontinuation of medication and go to the home to ensure that med is removed from the medication box and the medication is properly disposed. Proper medication disposal memo was posted in the homes (attachment # 7). |
11/17/2016
| Implemented |
| 6400.186(c)(4)(i) | Individual #1's ISP beginning 11/20/2015 and ending 11/19/2016 contained the same outcomes from the previous plan year without modification or update. | The program specialist shall make a recommendation regarding the following, if applicable: The deletion of an outcome or service to support the achievement of an outcome which is no longer appropriate or has been completed. | Program manager contacted individual's supports coordinator to discuss changing the outcomes to better represent goals for individual. ISP was updated as needed (attachment # 3 ). To ensure compliance with the regulation that the program specialist shall make a recommendation regarding the following, if applicable: The deletion of an outcome or service to support the achievement of an outcome which is no longer appropriate or has been completed, program managers will participate in quarterly chart training and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with ISP requirements. Furthermore, IDD Compliance Officer will complete monthly audit of a sample of client charts, as assigned to ensure compliance. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
11/22/2016
| Implemented |
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