| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(18) | The program specialist did not train all of the staf in this home that has direct contact with the Individual in rhe health and safety needs. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | program specialist will be retrained on the job duties. This training will be performed by Director, Kasey Bradley, During this training, the need for Direct services workers to be trained on the content of health and safety needed relevant to the individual. Program Specialist will be responsible to provide this training to all current a new employees working as direct services workers. Compliance specialist will ensure this training is completed. He will monitor this training during quarterly record reviews. completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.62(c) | A clear spray bottle was marked with 1/4 cup of bleach to one cup of water. This is not in the orginal container. In the basement area a clear spray bottle was a blue liquid, not in its orginal container. | Poisonous materials shall be stored in their original, labeled containers. | Unmarked bottles will no longer be used to contain the recommended mixture of bleach and water that was given to Crossroads Services, Inc. by the Department of Health. The new process will be using 1 Tablespoon of bleach per spray bottle (32oz.). The mixture will be used then discarded after every use so that no unmarked bottles are left in the home. Residential Supervisor, Beth Zeth will be in charge of ensuring this process is happening. This process has been put in place as of April 12, 2017.
The spray bottle of blue liquid was removed and discarded immediately. Residential Supervisor, Beth Zeth is now in charge of making sure all poisonous material are kept in their original/labeled containers. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. |
04/12/2017
| Not Implemented |
| 6400.64(a) | The exhust fan in the downstairs bathroom was covered in dust. The down stairs bathroom ceiling had mulitiple organge/brown mold stains. | Clean and sanitary conditions shall be maintained in the home. | Maintenance worker, Nate Monahan has cleaned the down stairs bathroom ceiling area. The bathroom ceiling is now free of any orange/brown stains as of May 19, 2017. Maintenance worker, Nate Monahan will be purchasing a new exhaust fan for the downstairs bathroom by June 19, 2017. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. attachment 10 |
06/19/2017
| Not Implemented |
| 6400.66 | Lights above bathtub was not operable. There was one light out in an Individuals bedroom. Lights above the mirror in the down stairs bathroom not operable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance worker, Nate Monahan has fixed/replaced all non-operable lighting as of May 18, 2017. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected.n attachment 10 |
05/18/2017
| Not Implemented |
| 6400.67(a) | There was a knob missing off the kitchen drawer and a large pool of water under the kitchen sink. The washer/dryer had a large hole punched in the plastic door. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance worker, Nate Monahan has replaced the missing knob on the kitchen drawer as of May 17, 2017. (Attachment 10)
Maintenance worker, Nate Monahan has discovered a leak within the piping under the kitchen sink and has fixed the leaking pipe as of May 16, 2017. This piping will be monitored by Maintenance worker, Nate Monahan for any other leaks.
The dryer with the cracked door is being replaced and will be installed by June 19, 2017. Maintenance worker, Nate Monahan will be responsible for making sure the new dryer will be installed by June 19, 2017. The washer is in good working order and has no issues at this time.
Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. |
06/19/2017
| Not Implemented |
| 6400.68(b) | The water temperature in the downstairs bathroom was tested at 133.8F | Hot water temperatures in bathtubs and showers may not exceed 120°F. | It has been determined that staff have been periodically turning the water temperature up on the water heater which has resulted in the high temperature readings. Maintenance worker, Nate Monahan has contacted Rhodes Plumbing and Heating and they are looking in to options of locking the temperature control knob on the water heater itself. Maintenance worker, Nate Monahan will be in charge of making sure this issue is resolved by June 19, 2017. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. |
06/19/2017
| Not Implemented |
| 6400.72(b) | The side screen door has a rip along the bottom of the screen. The side door exit did not open easily. | Screens, windows and doors shall be in good repair. | Maintenance worker, Nate Monahan will be repairing the ripped screen along the bottom edge of the side screen door by June 19, 2017. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. |
06/19/2017
| Not Implemented |
| 6400.141(c)(9) | Individual #1 did not receive a prostrate exam completed on 6/29/16. The physical indicated that Individual #1 refused the exam, there where no other attempts made to get another prostrate exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | health coordinator will be retrained on job duties. Director, KAsey Bradley, will provide the training. The training will include the need for a prostate exam for men 40 and over annually. If the individual refuses the exam the health coordinator will ask the dr. for a written note stating that the exam is medically unnecessary at the time. Health coordinator will be required to continue to educate the individual on the importance of prostate health. The compliance Specialist will perform a record review quarterly. During this review, compliance specialist will be responsible to ensure that the prostate exam is done annually or documented properly by the physician. completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.141(c)(10) | Individual #1's 6/29/16 physical exam indicated not free from communicable disease. There where no specific precautions listed. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The individuals physical has been updated by the PCP. (attachment #14) The area for special precautions has been completed. Health coordinator will be responsible to ensure that the physicals are filled out completely. Compliance specialist will do a record review quarterly. During these reviews, he will identify any missing information on a physical and have the health coordinator address the issue. 6/30/17 completion date. |
06/30/2017
| Not Implemented |
| 6400.142(a) | Individual #1 has upper and lower dentures. The last cleaning was 2/26/15 on a dental appointment form. There were no other forms with the dentist signature on it. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | HEalth Coordinator, Amanda Barnhart, will be retrained on job duties. This training will include what documentation is required regarding dental exams. The training will include a need for the dentist signature on the medical consult form/appointment form yearly. Kasey Bradley will provide this training. Compliance specialist will ensure that yearly (or as the ISP indicates) dental exams have written documentation relating to the exam have proper documentation with Dentist signature. Compliance Specialist will monitor this during quarterly record reviews. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.142(g) | the dental hygiene plan 1/13/16 and 3/23/17 where not updated annually. The dentist recorded on the 12/22/15 form that Individual #1 needs to clean & brush teeth and partials daily and remove partial at night. This information is not located in the dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | health Coordinator will be retrained on job duties. Kasey BRadley, Director, will provide the training. The training will include the completion and update of the individuals dental hygiene plan. The dental hygiene plan will be updated annually. they will include any existing or new recommendations by the individuals dentist. Dental hygiene plans will be kept in the medical book for the individual. Quarterly REcord Reviews will be performed by the compliance specialist. During these reviews the compliance specialist will ensure that the plans are updated annually and include relevant instructions or recommendations by the dental provider. correction date 6/30/17 Attachmetn#3 |
06/30/2017
| Not Implemented |
| 6400.165 | All of Individual #1's medications on 3/31/17 at 8am where not signed as given. There was nothing listed on the back of the MAR indicating why medications where not signed for. | Documentation of medication errors and follow-up action taken shall be kept.
| All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the training and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. Compliance Specialist will conduct quarterly record reviews, during these reviews he will identify any errors and notify health coordinator. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.167(a) | Individual#1's medication log for Feb 2017 2/16/17-2/23/17 was administered Propranolol 10 mg BID for 1 week then increase. There is no script or doctor¿s apt in the record to indicate this was prescribed. Also indicated propranolol 20 mg BID for high blood pressure was given 2/23/17 to present date. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. | Health coordinator, Amanda Barnhart, will be responsible to include a written documentation for all medicatin changes in the individuals medical record book. Director, Kasey BRadley, will train Health Coordinator on the appropriate written documentation ( prescription, note on the medical consult form, written not from Dr. with signature) A record review will be done quarterly by Compliance specialist. Durning these reviews compliance specialist will ensure that all new or changed medication has a written documentation/order in the individuals record. Completion Date 6/30/17. |
06/30/2017
| Not Implemented |
| 6400.181(a) | Individual #1 had an assessment on 1/12/16 and there was no date on the current 2017 assessment. | 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. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for a date to be on the current assessment. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(d) | The program specialist did not date and pre- populated a signature on the the assessment. | The program specialist shall sign and date the assessment. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for the Program Specialist to sign in ink the assessment. No prepopulated signatures will be utilized. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(3)(i) | The 2017 assessment for Individual #1 did not contain acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need of assessment of the acquisition of functional skills. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(ii) | The 2017 assessment did not contain progress and growth in motor and communication for Individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the areas of motor and communication skills. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(iii) | The 2017 assessment did not contain progress and growth in activities of residential living for Individual #1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of activities of residential living. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(iv) | The 2017 assessment for Individual #1 did not contain progres and growth in personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of personal adjustment. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(v) | The 2017 assessment for Individiual #1 did not contain progress and growth for 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. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of socialization. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Implemented |
| 6400.181(e)(13)(vi) | The 2017 assessment for Individual #1 did not contain progress 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. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of recreation. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(vii) | The 2017 assessment for Individual #1 did not contain progress in the area of financial independence, | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of financial independence. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(viii) | The 2017 assessment for Individual #1 did not contain progress in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of managing personal property. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(e)(13)(ix) | The 2017 assessment for Individual #1 did not contain progress in the area of community intergration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for progress and growth in the area of community integration. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.181(f) | The ISP meeting for Individual #1 was held on 3/16/17 and the program specialist indicated on 4/1/17 the assessment was hand delivered to all team members on 3/16/17. All team members where not present at the meeting and did not receive a copy of the 2017 assessment. | (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).
| An assessment training has been developed for new and current Program Specialists. (Attachment#1) . Kasey Bradley, Director, will provide the training's upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include the need for the assessment to be sent to all team members 30 days prior to the ISP. . Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that the program Specialists are completing the assessments properly. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.183(4) | Individual #1's ISP did not have a plan to decrease 1:1 supervision. | 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. | Individual #1s Support coordinator was notified that the ISP did not include the plan for the decrease in 1:1 supervision. Crossroads Services Inc. (attachment #7). Program specialist , Amanda Krestar, will be responsible to follow up with the Supports Coordinator to verify that the ISP has been updated. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all ISPs include a plan to decrease 1;1 supervision as needed. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.183(6)(i) | Individual #1 ISP did not include an assessment to determine the cause or antecedents of the behavior. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. | Individual #1s Support coordinator was notified that the ISP did not include an assessment to determine the cause or antecedent of the behavior (attachment #7) Program specialist , Amanda Krestar, will be responsible to follow up with the Supports Coordinator to verify that the ISP has been updated. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all ISPs include an assessment to determine the cause or antecedent of the behavior. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.183(6)(ii) | Individual #1's ISP did not include a protocol for addressing the underlying causes or antecedents of the behavior. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | Individual #1s Support coordinator was notified that the ISP did not include A protocol for addressing the underlying causes or antecedents of the behavior. (attachment #7) Program specialist , Amanda Krestar, will be responsible to follow up with the Supports Coordinator to verify that the ISP has been updated. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all ISPs include a protocol for addressing the underlying causes or antecedents of the behavior.Completion Date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.183(6)(iii) | Individual #1's ISP did not include the method and timeline for eliminating the use of restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | Individual #1s Support coordinator was notified that the ISP did not include the method and time line for eliminating the use of restrictive procedures. (attachment #7) Program specialist , Amanda Krestar, will be responsible to follow up with the Supports Coordinator to verify that the ISP has been updated. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all ISPs include the method and timeline for eliminating the use of restrictive procedures. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.183(6)(iv) | Individual #1's ISP did not include a protocol for intervention or redirection without utilizing restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. | Individual #1s Support coordinator was notified that the ISP did not include the method and time line for eliminating the use of restrictive procedures. (attachment #7) Program specialist , Amanda Krestar, will be responsible to follow up with the Supports Coordinator to verify that the ISP has been updated. Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all ISPs include a protocol for intervention or redirection without utilizing restrictive procedures.. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.184(a) | Individual #1 did not attend and sign the ISP signature sheet for ISP meeting on 3/16/17. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 6400.186 (relating to ISP review and revision). | All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. Program Specialist was trained on the importance of the individual attending the ISP. Program Specialist will be responsible to ensure that the individual signs the ISP attendance sheet. Kasey Bradley will provide the training to all current and newly hired Program Specialists. (attachment #6) Compliance Specialist, Andrew Hamilton, will perform a quarterly record review. During the review, he will ensure that all individuals sign the ISP attendance sheet. Completion Date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.185(b) | Individual #1's ISP indicated he needed 10 minutes visual checks at home. This has not been implemented. | The ISP shall be implemented as written. | A meeting with Behavior Support Specialist has been arranged for 5/22/17. (attachment #5). During this meeting a chart will be discussed to indicate that the 10 minute visual checks are being performed. The plan will also be update to specifically identify when these checks are necessary i.e. When individual #1 is at a heightened psychiatric state. Program Specialist, Amanda Krestar, will follow up with behavior supports and support coordinator in order to ensure the restrictive procedure plan is updated.and added to the ISP. Compliance officer, Andrew Hamilton, will perform a record review quarterly to ensure that the individuals ISP reflects the current BSP. completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.195(b) | Individual #1's restrictive plan was not developed by program specialist. The program specialist did not participate in the implantation of the restrictive plan. | The restrictive procedure plan shall be developed and revised with the participation of the program specialist, the individual's direct care staff, the interdisciplinary team as appropriate and other professionals as appropriate.
| All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. these duties will include attending the Human Rights Committee meetings in order to participate in the implementation of the Restrictive Procedure Plan (Attachment #4) Compliance Specialist will perform quarterly reviews. During these reviews he will ensure that there is documentation that the program specialist attended the HRC meeting and help develop the restrictive procedure plan. 6/30/17 completion date |
06/30/2017
| Not Implemented |
| 6400.195(d) | Individual #1's restrictive plan wasn't revised to indicate no internet currently on tablet or available at the house. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| A meeting with Behavior Support Specialist has been arranged for 5/22/17. (attachment #5). This meeting will encompass removing any unnecessary restrictions such as internet and tablet usage. The time restrictions for restrictive plan(s) will be identified. Amanda Krestar, Program Specialist, will followup with the behavior support specialist to ensure the plan is updated. Compliance specialist, Andrew Hamilton, will do quarterly record reviews. During the review he will ensure that the behavior plan is current and identifies restrictions appropriately. COmpletion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.195(e)(6) | Individual #1's restrictive plan didn't include amount of time restrictions are implemented. | The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter.
| A meeting with Behavior Support Specialist has been arranged for 5/22/17. (attachment #5). This meeting will encompass removing any unnecessary restrictions such as internet and tablet usage. The time restrictions for restrictive plan(s) will be identified. Amanda Krestar, Program Specialist, will followup with the behavior support specialist to ensure the plan is updated. Compliance specialist, Andrew Hamilton, will do quarterly record reviews. During the review he will ensure that the behavior plan is current and identifies restrictions appropriately. COmpletion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.195(f) | Individual #1's restrictive plan indicated date collected on daily data charts. | The restrictive procedure plan shall be implemented as written.
| .A meeting with Behavior Support Specialist has been arranged for 5/22/17. (attachment #5). Any daily documentation and charts identified necessary will be included in the plan and implemented in the residential home. Amanda Krestar, Program Specialist, will followup with the behavior support specialist to ensure the plan is updated. Compliance specialist, Andrew Hamilton, will do quarterly record reviews. During the review he will ensure that the behavior plan is current and identifies restrictions appropriately. Completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.205 | Individual #1's record did not contain when restrictions with tablet were done. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record.
| A meeting with Behavior Support Specialist has been arranged for 5/22/17. (attachment #5). This meeting will encompass removing any unnecessary restrictions such as internet and tablet usage. The time restrictions for restrictive plan(s) will be identified.completion date 6/30/17 |
06/30/2017
| Not Implemented |
| 6400.213(11) | Individual #1's 2017 assessment states supervision 1:1 continues supervision in all settings with in hearing range if he is at home with just staff and house mates. Eye sight at day program with clear path if intervention is necessary. If women and children are around arms length outdoors. outdoors with male peers with in eye sight with a clear path. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | A training on content discrepancies has been developed. (Attachment#2) All current and new program Specialists will be trained. Kasey Bradley, Director, will provide the training's upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. Any other team members, employed by Crossroads Services Inc., who contribute to the development of the ISP, Assessment, or other documentation will also be required to have this training. Compliance specialist will perform a record review quarterly ton ensure that the program specialist is completing documentation properly. |
05/19/2017
| Not Implemented |
| 6400.214(b) | Individual #1's 2017 assessment wasn't kept in the individuals file. The P.S. stated to licensing on 4/10/17 that they were waiting to file until the new ISP was done. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. | An assessment training has been developed for new and current Program Specialists. (Attachement#1) . Kasey Bradley, Director, will provide the trainings upon hire and then annually thereafter. All Program specialists have been or will be trained on how to develop an assessment. This training will include where the assessment must be kept at all times. This includes any updated assessment as well as an annual assessment |
05/19/2017
| Not Implemented |