| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, date of admission 12/21/17, signed and dated acknowledging receipt of the information on rights 1/25/18. | 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. | The plan to alleviate this violation moving forward is that AMA has implemented an Admission Process that utilizes a Transition plan to review all individuals referred for services at AMA In the Transition Plan, On Move in Day , the Program Specialist will Review the Statement of Individual Rights with the individual and or the individual's parent, guardian or advocate and have them sign this form. This review will occur annually thereafter.[Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are informed of individual right, timely and signed statements are kept. Immediately, upon admission and quarterly for 1 year, the CEO or designated management staff person shall audit all individuals statements acknowledge receipt of information of rights and the aforementioned tracking system to ensure all individuals are informed of individual rights timely and statement acknowledging receipt is kept. Documentation of audits shall be kept. (AS 5/1/18)] |
03/21/2018
| Implemented |
| 6400.44(b)(10) | The program specialist did not review, sign, and date the monthly documentation for Individual #1, date of admission 12/21/17. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes. | The plan to address this issue of non-compliance is that ISP Goal Data documentation has been implemented on 2.26.2018. With this in place, a monthly review will be generated on 4.9.2018. This ISP review will be provided to all member's of individual #1's team. The plan to alleviate this violation in the future is that AMA Support Serrvices has implemented a Monthly Review Process The Program Specialist is responsible for the monitoring and completion of this process. This process is, the Program Specialist will generate monthly documentation of an individual's participation and progress toward outcomes. [Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist of the responsibilities of program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall review all individuals' monthly documentation to ensure the program specialist reviews, signs and dates all individuals' monthly documentation of an individual's participation and progress toward outcomes as required. Documentation of audits shall be kept. (AS 5/1/18)] |
04/09/2018
| Implemented |
| 6400.81(k)(6) | There was not a mirror in the Individual #1's bedroom at the end of the hallway. | In bedrooms, each individual shall have the following: A mirror. | The plan of correction for this issue of non-compliance is to place a mirror in this individual's room. A mirror was placed in this individual's room on 3.2018. This individual has since broken this mirror. A new mirror will be secured to the wall in this individual's room. The plan to alleviate this violation moving forward is that AMA Support Services has implemented a Site Audit System. This site audit is a checklist that is comprised of 6400 regulations pertaining to physical site requirements. This site audit checklist is completed monthly by the House Manager and submitted to the Program Specialist by the 5th of each month. [Within 15 days of receipt of the plan of correction, the CEO or designee shall train the House Manager on completing the site audit check list and the corresponding regulations as per 6400.61-87 and the procedures to ensure regulatory requirements are met at all times. Documentation of the training shall be kept. Documentation of the audits of the checklist by the Program specialist shall be kept. (AS 5/1/18)] |
05/01/2018
| Implemented |
| 6400.110(b) | The smoke detector located in the hallway adjacent to the bedrooms was not operable. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The plan of correction for this issue of non-compliance is to replace the inoperable smoke detector in the hallway adjacent to the bedrooms with an operable smoke detector. This was completed on 3.20.2018.
The plan to alleviate this violation moving forward is that AMA Support Services has implemented a Site Audit System. This site audit is a checklist that is comprised of 6400 regulations pertaining to physical site requirements and fire safety. This site audit checklist is completed monthly by the House Manager and submitted to the Program Specialist by the 5th of each month. [On 4/18/18, an operable smoke detector was present in the attic of the home. Immediately, upon opening a home and continuing at least monthly, the CEO or designee shall check all homes to ensure all homes have a minimum of one operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Documentation of the checks shall be kept. (AS 5/1/18)] |
05/01/2018
| Implemented |
| 6400.113(a) | Individual #1, date of admission 12/21/17, did not have fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The plan of correction to address this issue of non-compliance is that individual # 1 will complete fire safety training on 4.9.2018. The plan to alleviate this violation moving forward is the implementation of the Admission process here at AMA. As outlined in the Admission Process, on the day of admission at AMA all individuals will complete emergency training. From this admission date, Individual Emergency Training will be completed annually.
The Program Specialist will be responsible for the completion of this initial and annual Individual Emergency Training. [Immediately and continuing quarterly for 1 year, the CEO or designee shall audit all individuals' fire safety training to ensure all individual are instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home, timely. (AS 5/1/18)] |
04/09/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 12/7/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The plan to alleviate this violation moving forward is that AMA Support Services has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician will include pertinent medical information to diagnosis and treatment in case of emergency. This Admission Process is the responsibility of the Program Specialist. [Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] |
03/21/2018
| Implemented |
| 6400.142(c) | There was not a written record of a dental examination for Individual #1. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | the plan of correction for this issue of non-compliance is to schedule a dental exam for Individual # 1. This exam is scheduled for 4.26.2018.The plan to alleviate this violation moving forward is that AMA Support Services has implemented an Admission Process. In the Admission Process , a Transition Plan is utilized to review all individuals referred to AMA Support Services. In this Transition Plan, Section 4: Client Admission Documents: Things to Collect is a Current Dental Exam ( within 1 year). The Admission Process is the responsibility of the Program Specialist. [Immediately and at least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure all individual have a written record of the dental examination, with the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended. Documentation of audits shall be kept. Within 15 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure all individuals have a dental examination as required. (AS 5/1/18)] |
03/21/2018
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks and there was not a date on the photograph. | 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 plan to address this issue of non-compliance is that the identifying marks missing from Individual # 1's record has been revised to include all identifying mark information. A date on Individual # 1's photo has been placed on the back of this photo. The plan on how this violation will be alleviated moving forward is-AMA has implemented the use of an electronic record system, Therap. Therap is a web-based service that provides an integrated system for documentation, reporting and communication. AMA has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, entering the individual's personal information in the Individual Data form in Therap is an identified step to be completed in this Transition Plan. In Section 4 of the Transition Plan: On Move in Day-taking a picture and uploading this photo into Therap on the Individual data form is an identified step in this Transition Plan. The Admission Process and completion of the Transition Plan is the responsibility of the Program Specialist.The Admission Process is supported in AMA's Policy and Procedure Manual; Section F: Program Record Keeping-F1: Individual Records-Procedure-Each record will include-Personal information including : name, sex, admission date, birthdate, social security #, race, height, weight, color of hair, color of eyes and identifying marks. Language and the means of communication spoken or understood by the individual and the primary language used in the individual's home, if other than English. Religious affiliation, next of kin and a current dated photograph.I [Immediately and continuing at least quarterly for 1 year, the CEO or designee educated in the required information in individuals' records as per 6400.213(1)-(14) shall audit all individuals' records to ensure all required information as per 6400.213(1)-(14) is included. Documentation of audits shall be kept. (AS 5/1/18)] |
03/22/2018
| Implemented |