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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(f) | Individual #1, date of admission 5/06/2013, does not have a dental hygiene plan. Individual #1's assessment completed 7/14/2023 states she is independent in brushing her teeth but does not like to floss. Individual #1's individual support plan, last updated 9/26/2023, states the individual is independent in brushing her teeth twice a day, although she refuses to floss, and needs reminders and prompts to do so. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Emmaus¿ Mentorship & Internship Coordinator/Program Specialist, will add an addendum to individual's #1 Emmaus Annual Assessment to include a ¿Dental Hygiene Plan¿ that will describe the level of support needed for her to successfully brush her teeth and floss. This addendum will be added in and then sent out to person #1 and her team by 10/20/23. |
10/20/2023
| Implemented |
| 6400.50(a) | Direct Service Worker #1 completed orientation 7/05/2023 through 7/07/2023, and there was no record of the training sources, content, and lengths of the trainings. Direct Service Worker #2 completed orientation 4/21/2023 through 4/24/2023, and there was no record of the training sources, content, and lengths of the trainings. Direct Service Worker #3 completed orientation 5/04/2023 through 5/06/2023, and there was no record of the training sources, content, and lengths of the trainings. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | 6400.50a Orientation including sources of training, number of minutes/hours for training completion, full names of sources of training (not initials of trainers), specific content information.. 6400.50a Our documentation form for Orientation gives more credit now, including Training sources, duration mins/hours, Trainer name and spell out names on the documentation form- not initials. Emmaus updated our Orientation checklist upon a new hire's training. The form was completed on-site of the Inspection on 9/28/23 by Emmaus CEO. |
10/20/2023
| Implemented |
| 6400.182(c) | Individual #1's assessment completed 7/14/2023 states the individual is able to evacuate in 2 1/2 minutes independently and with verbal prompts. Staff interview conducted 9/26/2023 confirmed the individual is able to evacuate independently, but at times may need verbal prompts to stop what she is doing and exit the home. Individual #1's individual support plan, last updated 9/26/2023, states the individual can evacuate independently. Individual #1's assessment completed 7/14/2023 states the individual completed a residential goal to improve self-medicating skills. She will initiate the process and identify which meds to take at which time. Individual #1's individual support plan, last updated 9/26/2023, states the individual accomplished a goal of self-medicating but also states she needs support to take her medications as prescribed and needs assistance with medical follow up such as taking her medication. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 6400.182c Matching Goals and the Assessment. Individual #1's Annual Assessment was updated to reflect that she is self-medicating and this is indicated in her ISP as well. The two documents should match appropriately with the same information to prevent confusion. Also to match that she is able to evacuate without verbal prompting.
Individual # 1's Annual Assessment will include an addendum on 10/20/23, to demonstrate that she is independent with taking medication and evacuation. The team including the Residential Advisor has assessed individual #1 to be independent with Medication Administration and evacuation and found her to be independent in both areas. Individual #1 also has up to an hour of Alone time while in the home and this is important to her and for her. The SC has been notified as to the matching information required into the ISP. An addendum was made to the Annual Assessment at the inspection, on-site on 9/27/23. |
10/20/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(2) | The program specialist is responsible development of ISPs including that individuals' current ISPs and current assessments contain the same information. Individual #1's ISP, updated 8/1/19, states that the individual can be unsupervised for up to 8 hours. Individual #1's Assessment, dated 12/17/18, states that the individual can be unsupervised for up to 5 hours. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Emmaus Program Specialists will compare the current ISP and current Assessment at least quarterly. They will send an email to the SC regarding any changes or discrepancies. Emmaus utilizes a form called Change Alert II to identify any requests for changes to the ISP. A training was held on 8/28/19 with Kelly Stillwell, Director of IDD Services, Residential Advisors and Program Specialists, Kristy Weaver and Anthony Bradley. [As per CEO, the Director of IDD Services trained the PS(s) on the reviewing the assessments quarterly to ensure assessments are revised and updated as needed based on the individuals' current needs and the individual plans are revised based on the current assessments. Documentation of the training shall be kept. At least quarterly 1 year, the CEO or designee shall audit a 10% sample of individuals' assessments and Individuals' plans to ensure individuals' plans are initially developed, revised annually and revised when an individual's needs change based upon a current assessment. Documentations of the audits shall be kept. (DPOC by AES,HSLS on 9/24/19)] |
09/11/2019
| Implemented |
| 6400.182(c) | Individual #1's ISP, updated 8/1/19, states that the individual can be unsupervised for up to 8 hours. Individual #1's Assessment, dated 12/17/18, states that the individual can be unsupervised for up to 5 hours. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1's current ISP and current Assessment were reviewed by the Program Specialist and the SC, was notified to include up to 8 hours of alone time. All Residential Advisors and Program Specialists were asked to compare ISP's and Assessments for discrepancies on 8/23/19. A training was held on 8/28/19 with Kelly Stillwell, Director of IDD Services, Residential Advisors and Program Specialists, Anthony Bradley and Kristy Weaver. [As per CEO, the Director of IDD Services trained the PS(s) on the reviewing the assessments quarterly to ensure assessments are revised and updated as needed based on the individuals' current needs and the individual plans are revised based on the current assessments. Documentation of the training shall be kept. At least quarterly 1 year, the CEO or designee shall audit a 10% sample of individuals' assessments and Individuals' plans to ensure individuals' plans are initially developed, revised annually and revised when an individual's needs change based upon a current assessment. Documentations of the audits shall be kept. (DPOC by AES,HSLS on 9/24/19)] |
09/11/2019
| Implemented |
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