| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1 does not have a statement of rights on file.
Individual #2 does not have a statement of rights on file.
| Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Individuals #1 and #2 have signed statement of rights on file in the home.
The home will make sure that they obtain statement of rights for individuals upon admission and annually.
A copy of the individual's statement of rights will be kept on file in the home.
Administration will audit individual's records at least annually to ensure statement of rights are on file in the home.
|
11/06/2015
| Implemented |
| 6400.46(f) | Staff #1's date of hire was 02/01/2013. The initial fire training was held on 03/20/2013. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1's fire safety training date was a typographical error.
It is the home's policy for all new staff to be trained in fire safety their first day of working.
The home will ensure that all staff are trained in fire safety on their first day of hire and annually thereafter.
A copy of the staff's fire safety training will be kept on file in the home
Administration will audit the staffing records at least annually to ensure that all staff's fire safety records are accurate and available.
(a record review of all staff records will be completed within 30 days of receipt of this plan to identify any staff out of compliance with this regulation. The director of the program is responsible to ensure all staff member's receive the initial fire safety training before working with individuals. The initial fire safety training will be included on the new staff orientation training packet. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.46(h) | Staff #1's date of hire was 02/01/2013. The initial First Aid training date was 08/13/2013. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | The home will make sure that all staff have first aid/CPR training within 6 months of working
The home will maintain a copy of the staff's first aid/CPR training on file in the home.
Any staff that does not comply with obtaining their first aid/CPR training within 6 months of being hired will be suspended until they obtain the training.
(A record review of all staff records will be completed within 30 days of receipt of this plan to identify any other staff members out of compliance. The new hire orientation packet will include intial first aid training. new staff will not be permitted to work until initial first aid training is received. the director of the program will use a tracking system to ensure all staff have first aid training annually and all new staff have initial first aid training prior to working with the individual. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.46(i) | Staff #1's date of hire was 02/01/2013. The First Aid/CPR training was held on 08/13/2013. | 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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | All staff will have first aid/CPR training within 6 months of being hired
Any staff that does not comply and have training within 6 months will be suspended until they receive their first aid/CPR training.
A copy of the staff's first aid/CPR training will be kept on file in the home.
Administration will audit the staffing records at least annually to ensure that all staff have first aid/CPR training within 6 months of being hired and at least bi-annually thereafter.
(A record review of all staff records will be completed within 30 days of receipt of this plan to identify any other staff members out of compliance with this regulation. The director of the program will use a tracking system to ensure all staff have first aid and cpr training within 6 months of hire and annually or the time allotted on the certification thereafter. Staff members without this training will not be permitted to work alone with an individual. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.64(a) | The second floor bathroom tub and shower had a black substance along the tub floor and shower walls.
| Clean and sanitary conditions shall be maintained in the home. | The second floor bathtub/shower was cleaned during the inspection.
The individuals and staff will follow the cleaning checklist and clean the home daily.
The staff will walk through the home daily to ensure that the bathrooms are clean.
Bathrooms found unclean will be cleaned immediately.
The residential manager will walk through the home weekly to ensure that bathrooms are clean.
The program manager will walk through the home monthly to ensure that bathrooms are clean.
|
11/06/2015
| Implemented |
| 6400.67(a) | The left side cabinet door above the stove was unhinged.
The second floor bathroom vanity was scratched and worn.
Individual #1's bedroom dresser was missing handles on the first and second left side drawers.
| Floors, walls, ceilings and other surfaces shall be in good repair. | The hinge on the stove was off track at the time of inspection.
The stove hinge was put back on track.
The vanity in the second floor bathroom has been painted.
The staff will walk through the home daily to ensure that the home is in good repair.
Any defects or deficiencies that the staff can fix will be fixed immediately.
Any defects or deficiencies that need additional attention will be immediately reported to maintenance for repair.
The residential manager will walk through the home weekly to ensure that the home is in good repair.
The program manager will walk through the home monthly to ensure that the home is in good repair. |
11/06/2015
| Implemented |
| 6400.68(b) | Water temperature in the individuals' bathroom was 123.2 | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The home telephoned the plumber to have the water temperature reduced during the inspection.
The plumber turned down the thermometer on the water heater.
The home will check the water temperature monthly to ensure that it does not exceed 120F.
If the water temperature exceeds the 120F the home will have the thermostat on the water heater adjusted immediately.
(The house manager will test the hot water temperature from the shower/tub used by the individual on a monthly basis. The temperature of the hot water will be recorded on the fire drill log. the fire drill log will be edited to add a space for the hot water temperature. The program specialist will calibrate the thermometer monthly to ensure accurate readings. The calibration will be recorded and the documentation will be kept. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.112(e) | Fire drills held during sleeping hours occurred on 07/25/2014 and 8/11/2014. | A fire drill shall be held during sleeping hours at least every 6 months. | The home will conduct fire drills during sleeping hours every 6 months.
A copy of all fire drills will be kept on file in the home and will include the drills conducted during sleeping hours.
Administration will audit the fire drills at least annually to ensure that drills are being conducted monthly and that drills conducted during sleeping hours are facilitated every 6 months.
(The director will audit the fire drill records every 6 months to ensure that asleep fire drills are occuring every 6 months. Should an asleep fire drill be missed the 6th month, an asleep drill will be completed that same month to meet the regulation. The program specialist is responsible to ensure the home is completing the asleep drills every 6 months. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.113(c) | Individual #1's fire safety training record was not available to review.
Individual #2's fire safety training record was not available to review.
| A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Individuals will participate in fire safety training at least annually
A record of the individual's fire safety training will be kept on file in the home.
Administration will audit the individual's record at least annually to ensure that a copy of the individual's fire safety training is available in the home.
(a record review will be completed within 30 days of receipt of this plan to identify any other staff records out of compliance with fire safety training. ALL staff will be trained by a fire safety expert within 30 days of reciept of this plan if they are not trained. Documentation of this training will be sent to BHSL within 5 days of completion. The director will use a tracking system to ensure all staff are trained annually. verbal and written notification will be sent to the staff member and supervisor 60 days prior to the impending expiration of the training. Another notification will be sent 30 days prior to the impending expiration. A copy of the notification will be kept in the staff member's record. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.141(c)(3) | Individual #2's record did not have a current immunization record for Diphtheria and tetanus. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #2's record has been updated to include her immunization record.
The individual's Diphtheria and tetanus were updated on the immunization record.
The home will have individual's primary care physicians complete the immunization portion of the individual' physical records.
The home will request that the physician record that information at least annually on the individual's medical record for the home.
The home will keep a copy of the individual's immunization record on file in the home.
Administration will audit the individual's record at least annually to ensure that immunization records are accurate and present in the home.
(A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other individuals out of compliance. The program specialist is responsible to review the physical exam forms upon return from the physical examination to ensure all information is completed on the physical. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.141(c)(7) | Individual #1 did not have a breast examination completed during her physical exam, dated 04/30/2014, or during the GYN examination on 04/29/2014. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The home will make sure that the physician performs a breast exam at least annually
A copy of the physician's exam will be kept on file in the home.
Administration will audit the record at least annually to ensure that the individual has had an annual breast exam and to ensure that it is documented in the record.
(A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other individuals out of compliance. The program specialist is responsible to review the physical exam forms upon return from the physical examination to ensure all information is completed on the physical. the director of the program will utilize a tracking system to ensure all individuals are receiving health care in accordance with the regulation. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.151(a) | There is no documentation that a physical examination was completed prior to Staff #1's date of hire.
Staff #2's hire dated was 06/19/2014. The most recent physical examination date was 07/08/2014.
Staff #3's most recent physical examination is dated 10/19/2011.
| 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. | Any staff hired by the home will have physical examinations prior to their date of hire.
Physical examinations will documented on a form provided by the home to the potential staff.
A copy of the staff's physical examinations will be kept on file in the home.
Administration will audit employee records at least annually to ensure that all staff physical evaluations are accurate and available in the home.
Staff will not be allowed to work in the home until they provide administration with a copy of a physical examination.
(A record review of all staff in the agency will be completed within 30 days of receipt of this plan to identify any other staff out of compliance. The director will utilize a tracking system to ensure all staff have a physical exam prior to hire and every 2 years after. The director will notify the staff member and their supervisor of the impending expiration of the physical exam 60 days prior to the expiration and again 30 days prior. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.171 | There was an uncovered can of crushed pineapple in the freezer. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The can of pineapples in the freezer was discarded during the inspection.
The individual's and their staff will clean the refrigerator weekly.
Any food found uncovered in the refrigerator will be immediately disposed of.
The staff will make sure that food is put in the refrigerator covered and/or properly sealed.
(The home supervisor will conduct weekly physical site inspections to ensure all areas of the home are clean. Staff will receive training during staff meetings on the importance of food storage. The home supervisor will ensure all staff are aware of the regulation and that all food is stored properly. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment, dated 07/21/2014, did not include recommendations for specific areas of training, programming and services.
Individual #2's assessment, dated 11/01/2014, did 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. | The home will update the individual's assessment to include recommendations for specific areas of training, programming and services.
Annually the administration will assess the individual to make recommendations for training, programming and services.
This information will be documented on the individual's annual assessment.
A copy of the individual's assessment with recommendations for specific areas of training, programming and services will be kept on file in the home.
Administration will audit the individual's record at least annually to ensure that the annual assessment is on record in the home and that it includes recommendations for specific areas of training, programming and services.
Any recommendations found to be missing from the individual's assessment will be immediately assed to the annual assessment.
(A record review of all individual records will be completed within 30 days of receipt of this plan to identify any other assessments out of compliance. Recommendations will be added to each assessment within 30 days of receipt of this plan. The program specialist will be responsible to ensure all assessments include the required information. The program specialist will review the regulations surrounding the assessment within 30 days of receipt of this plan. AH 11.5.2015) |
11/06/2015
| Implemented |
| 6400.183(4) | Individual #1's Individual Support Plan(ISP) did not include a protocol targeted to reduce the need for intensive staffing. Individual #1 has 2:1 staffing ratio during the day and a 1:1 staffing ratio overnight. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | The home's administration will participate in individual's ISP meetings to ensure that the protocol targeted to reduce intensive training is included in the individual's ISP.
Administration will meet with the individual, their behavior specialist, and supports coordinator to work on protocol that is appropriate for the individual to reduce staff.
A copy of the individual's ISP that includes the protocol targeted to reduce staffing will be kept on record in the home.
The home will audit the individual's record at least annually to ensure that the protocol targeted to reduce staffing is included in the individual's ISP.
(A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other plans out of compliance. All individuals with intensive supervision needs will be have their ISP's updated to include a plan to reduce the intensive staffing. The program specialist is responsible to notify the supports coordinator and have this information added to the ISP. documentation of the notification to the Sc will be kept in the individual's file. The program specialist is responsible to review the ISP upon return from the SC to ensure all information is in the plan. AH 11.5.2015) |
11/25/2015
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include next of kin information. | 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. | The individual's next of kin was added to the individual's record.
The home will document individual's next of kin information in their record upon admission to the home.
The residential manager will audit individual records at least twice annually to ensure all required information is present.
The program manager will audit individual records at least annually to ensure that all required information is present in the record.
Any required information including individual's next of kin will immediately be added to the record and recorded in the quality management.
(a record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance with this regulation. Any other records will be immediately updated to include the information. AH 11.5.2015) |
10/23/2015
| Implemented |
| 6400.213(8)(ii) | Individual #2's Individual Support Plan(ISP) meeting was held on 11/07/2014, however the signature sheet was not available to review. | Each individual's record must include the following information: A copy of the signature sheets for the annual update meeting. | The home will keep a copy of all support plan meeting signature sheets on site in the individual's record.
After the annual ISP meeting the home will copy the ISP signature sheet.
A copy of that ISP signature sheet will be kept on file in the individual's record on site.
The residential manager will audit the individual's record at least twice annually ensuring that all ISP signature sheets are present in the record.
If a sheet is missing or misplaced the residential manager will call the supports coordinator to obtain an additional copy of the ISP signature sheet.
The program manager will audit individual's records at least annually to ensure that ISP signature sheets are present in the record.
(a record review will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. if other records are found to be missing a signature sheet, the program specialist will request a copy and add it to the file immediately. AH 11.5.2015) |
10/23/2015
| Implemented |