Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(f) | All of the fire drills completed from July 2023 through November 2023 used the front door exit to evacuate the property. | Alternate exit routes shall be used during fire drills. | The provider cannot remedy past fire drills. The form for recording fire drills has been updated and a fire drill will be conducted between 1/15-1/20 with a member of the administrative team to serve as training for program staff to exhibit thorough, accurate completion. |
02/08/2024
| Implemented |
6400.112(h) | (Repeat from Inspection Completed 7/25/23) The fire drills completed on 7/10/23 and 8/21/23 indicated that everyone met at the designated meeting place of "the living room." | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The provider cannot remedy past fire drills. The form for recording fire drills has been updated and a fire drill will be conducted between 1/15-1/20 with a member of the administrative team to serve as training for program staff to exhibit thorough, accurate completion. |
01/20/2024
| Implemented |
6400.141(c)(14) | (Repeat from Inspection held on 7/25/23) Individual #1's most recent physical completed on 11/13/23 does not identify information pertinent to treat/diagnose in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The RSS for Individual #1 will request clarification from the PCP and will attach the clarification to the current physical. Prior to obtaining the information, Individual #1 left the care of Maxcare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.141(c)(15) | (Repeat from Inspection held 7/25/23) Individual #1's most recent physical completed on 11/13/23 does not provide instructions about Individual #1's dietary needs. The physical documents that Individual #1 has needs around their "diet and weight loss." However, the physical does not identify what the needs are. | The physical examination shall include:Special instructions for the individual's diet. | The RSS for Individual #1 will request clarification from the PCP and will attach the clarification to the current physical. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.144 | (Repeat from Inspection held on 7/25/23) Individual #1 is diagnosed with Constipation and is prescribed PRN medication to treat constipation. A bowel movement protocol was developed on 9/5/23. The protocol does not clearly define when staff should administer the PRN medications for constipation. In addition, staff are to be tracking the individual's bowel movements. Tracking is not occurring. As of 8/2/23, Individual #1 was to drink 64 ounces of fluid a day. This is not being tracked. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The RSS will contact the PCP for clarification of the constipation PRNs. The Provider's RN will review and revise the constipation/bowel movement protocol for Individual #1. The plan will be reviewed by the PCP and staff will receive training on the steps of the plan as well as data recording for the PRN and plan. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed.
The RSS will review data daily and the agency RN will review data collection monthly. The agency RN will be available to staff for questions and support. The individual is no longer in the care of MaxCare and will not be returning to their care. Therefore, the bowel tracking, and fluid tracking will not be occurring for this individual. |
02/08/2024
| Implemented |
6400.181(c) | The most recent assessment completed on 11/9/23 was not documented as being based on instruments, interviews, notes, or observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The assessment will be updated to include verbiage to support the assessment was completed based on assessment instruments, interviews, progress notes and observations. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.181(d) | (Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 was signed and dated by the director of compliance, Staff #3. Staff #3 does not meet the requirements to serve as a Program Specialist. | The program specialist shall sign and date the assessment. | The provider submitted an exception request for Staff #3 to act as a program specialist. Until that request is approved, another staff with acceptable qualifications will acts as a program specialist. |
02/01/2024
| Implemented |
6400.181(e)(9) | (Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 indicates their hearing is within normal limits. However, Individual #1's most current ISP and their medical records document that Individual #1 has limited hearing in their left ear. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The assessment will be updated to include a more thorough description of the individual's hearing. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.181(e)(11) | (Repeat from 7/25/23) Individual #1's most recent assessment completed on 11/9/23 does not indicate if the individual has had a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | Information will be added to the assessment regarding the individual's psychological evaluations as applicable. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.214(b) | (Repeated Violation -- 7/25/23) At the time of the 12/19/23 physical site inspection, the Individual Support Plan available in the home for Individual #1 was dated 9/6/23. There was an update completed on 12/5/23. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The provider will print, file and train on the most updated version of the ISP. |
02/01/2024
| Implemented |
6400.44(c)(3) | Staff #3 does not meet the criteria to serve as a Program Specialist. Their Associate's degree is not from an accredited college or university. | A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with individuals with an intellectual disability or autism. | The provider submitted an exception request for Staff #3 to act as a program specialist. Until that request is approved, another staff with acceptable qualifications will act as a program specialist. |
02/01/2024
| Implemented |
6400.51(b)(1) | (Repeat from Inspection completed 7/25/23) No documentation was provided verifying that Staff #1 or Staff #2 completed training on Community Integration offered by ODP. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | All current staff will complete the myODP website training listed as acceptable under the Orientation guidelines for community integration by 2/1/24, though the training was provided to all staff hired prior to 07/2023, as listed on their program orientation. |
02/01/2024
| Implemented |
6400.165(f) | (Repeat from 7/25/23) Individual #1 takes medication to treat a psychiatric disorder. At the time of the inspection, an acceptable SEEN plan had not been developed for Individual #1. The SEEN plan does not document the desired and undesired outcomes. It does not identify acceptable alternatives. | 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. | The PS and agency RN will work with the prescribing provider to create an acceptable SEEN plan in accordance with the regulations, then the PS will appropriately train staff on said plan, to include data collection. Prior to obtaining the information, Individual #1 left the care of MaxCare and this was unable to be completed. |
02/01/2024
| Implemented |
6400.165(g) | (Repeat from 7/25/23) The quarterly psych med review held on 11/1/23 did not clarify whether Individual #1 was to continue taking their psychiatric medications. The quarterly Psych Med Review held on 9/1/23 did not list the reason that the psychiatric medications were prescribed to Individual #1. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The form used for quarterly psychotropic medication review has been updated. The prescriber will be contacted for clarification of information missing from previous appointments and they will be saved with the incomplete forms. The PS will be re-trained on the regulations regarding psychotropic medication management. |
02/01/2024
| Implemented |
6400.166(a)(4) | Individual #1 was prescribed Tylenol as needed for headaches on 10/4/23. This medication is not listed on the MAR along with all of the required information. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The provider will change pharmacies to a pharmacy knowledgeable on the regulation requirements for medication administration and records. The RSS will request updated PRN forms and prescriptions for all currently prescribed medications and confirm they are accurately listed on the MAR. Program staff will undergo training on the process for accurately recording PRN medication administration. |
02/01/2024
| Implemented |
6400.167(a)(1) | Individual #1 did not receive their Gavilax, Lybalvi, or Clonidine on 10/1/23. They did not receive their Symbicort, Lybalvi, or Clonidine on 11/19/23, 12/9/23, or 12/16/23. On 10/23/23, Individual #1 was taken to the Emergency Room and diagnosed with Scabies. They were prescribed Permethrin topical cream. This medication was not administered. | Medication errors include the following: Failure to administer a medication. | The individual was out of program for the dates in question, but it was not documented appropriately on the MARs. The MARs will be reviewed and updated. |
02/01/2024
| Implemented |
6400.169(a) | (Repeat from 7/25/23) Staff #4 and Staff #5 administered the Victoza injection to Individual #1. Staff #4 and Staff #5 did not receive the additional required training on subcutaneous injections. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | A record existed of staff receiving training to administer injection medication, but since the previous medication administration trainer has separated from the agency, it was not available for submission during this unannounced visit. At this time, there are no injection medications being administered. Should there be another need for this training, all program staff would be trained by a certified medication administration trainer and/or agency RN. |
02/01/2024
| Implemented |