| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Crossroad Services' certificate of compliance expired on 4/29/16. The self-assessment was completed on 11/17/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A self assessment will be completed 3-6 months prior to the expiration of CSIs license. The self assessment will be completed by compliance specialist Andrew Hamilton. Andrew Hamilton has been trained on the checklist for the self assessment (Attachment #11). |
04/28/2017
| Implemented |
| 6400.15(c) | The 11/17/16 self-assessment did not include a summary of violations. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Andrew Hamilton, Compliance specialist, will complete residential self assessments. He has been trained on the checklist and the self assessment process. Andrew will ensure that the assessment includes the summary of violations. (attachment #11) |
04/28/2017
| Implemented |
| 6400.22(c) | Approximately $6,728.00 was stolen from Individual #1. | Individual funds and property shall be used for the individual's benefit. | There is a current court case pending on an former employee who has been charge with stealing over 30,000 dollars of individuals funds. The case is represented by the Blair county District attorney. Until any future restitution is made by the former employee, CSI has given each individual who was affected by the theft the money which was stolen. A new employee, Jaime Zaliznock, now acts as rep payee for our individuals. She must submit a financial ledger monthly to the director for oversight. (Attachment#24) |
03/08/2017
| Implemented |
| 6400.22(e)(1) | There were no financial ledgers prior to June of 2016 for Individual #1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | There is a current court case pending on an former employee who has been charge with stealing over 30,000 dollars of individuals funds. The case is represented by the Blair county District attorney. Any financial ledgers prior to the thefts discovery were destroyed by the former employee. A new employee, Jaime Zaliznock, now acts as rep payee for our individuals. She must submit a financial ledger monthly to the director for oversight. Jaime must also scan the ledger in to CSIs computer system in order to have a copy to ensure they do not go missing at any future date. (attachment#25) |
03/08/2017
| Implemented |
| 6400.31(b) | Individual #1 was informed of his/her rights on 8/3/15 and not again until 8/29/16. | 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. | A record review was completed 2/28/17-3/2/17. All individuals have had their individual rights updated if they were late (Attachment #8). The program specialist was trained on Individual Rights and the expectation that all individuals receive the individual rights at least annually, (attachment # 9) Compliance Specialist will do a record review quarterly and sign and date that the Individual rights is current and correct. (attachment #10) |
04/30/2017
| Implemented |
| 6400.46(e) | Staff #1, hired on 10/24/16, and Staff #2, hired on 6/1/16, were not trained in program planning and rights. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | A new training has been added to our orientation. All employees are required read and summarize the following: Developing and using meaningful objectives (attachment #37) everyday lives packet Attachment # 38, charts on individual support planning- the big picture (attachment # 39) and Enhancing the quality of ISP foundations for individual support plan Development. |
04/30/2017
| Not Implemented |
| 6400.46(f) | Staff #1, hired on 10/24/16, and Staff #2, hired on 6/1/16, did not receive initial fire safety training. | 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. | All new hires will have fire safety training in their orientation. The Bethesda video "fire safety: key to survival" (attachment #29) has been added to the orientation curriculum. Jaime Zaliznock is responsible to ensure that all new hires watch the video and complete the training. |
04/30/2017
| Implemented |
| 6400.46(g) | REPEATED VIOLATION - 4/20/2015. There was no documentation of the 2015 and 2016 fire safety training for Staff #3. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | Fire safety training was completed with all residential staff on 3/7/17 by the Altoona fire department. (attachment#29) Compliance specialist will schedule fire safety training annually. He will ensure all staff attend. If staff do not attend, they will not be permitted to work in the homes until fire safety training is completed. |
03/07/2017
| Implemented |
| 6400.64(a) | There was a large area of mold covered concrete immersed in a large puddle of water on the basement floor.The basement floor had cat vomit in three places. | Clean and sanitary conditions shall be maintained in the home. | Nate Monahan, Maintenance worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. The basement floor was cleaned and all mold was removed and all cat vomit was cleaned. Nate will do quarterly walk throughs of each property and identify and fix any items needing repair or clean any areas in need. |
03/31/2017
| Implemented |
| 6400.73(a) | The 4 steps leading from the pool area to the basement did not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Nate Monahan, Maintenance worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. A railing has been added to the stairwell to the 4 steps leading from the pool area to the basement. (attachment #2) Nate will do quarterly walk throughs of each property and identify and fix any items needing repair. |
03/30/2017
| Implemented |
| 6400.76(a) | Lint, approximately the size of a baseball, was in the lint trap of the dryer. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Nate Monahan, Maintenance worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. There is now a checklist that employees need to complete following each load of laundry to ensure the lint is removed. Nate will do quarterly walk throughs of each property and identify and fix any items needing repair. |
03/31/2017
| Implemented |
| 6400.80(b) | Paint was peeling off the outside of the front windows. There was a plate littered with cigarette butts on the side porch. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Nate Monahan, Maintenance worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. )The chipping paint will be sanded and repainted when the weather permits. All cigarette butts have been removed and the employees must now use an ashtray and empty it after each use. Nate will do quarterly walk throughs of each property and identify and fix any items needing repair and free from unsafe conditions. |
05/30/2017
| Implemented |
| 6400.112(h) | REPEATED VIOLATION - 4/20/2015. The fire drill logs from August of 2015 to December of 2016 did not indicate if all individuals met at the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | A record review of the Fire drill logs was completed by Beth Zeth, residential supervisor. A new fire drill log is now in use (attachment #23) The new fire drill record includes an area that indicates that all individuals made it to the meeting place. |
03/08/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's 1/5/16 physical exam did not include health maintenance needs. This section was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Health coordinator was trained on the physical and the proper completion of a physical (attachment #17) The health coordinator completed a record review of residential physicals on 3/8/17. Any areas that were left blank on the physical were properly filled out. . Health coordinator will be responsible to do a record review of individuals quarterly Health coordinator will be responsible to ensure all areas of the physical are complete and no blanks are on the physical. |
04/30/2017
| Implemented |
| 6400.141(c)(14) | REPEATED VIOLATION - 4/20/2015. Individual #1's 1/5/16 physical exam 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. | Health coordinator was trained on the physical and the proper completion of a physical (attachment #17) The health coordinator completed a record review of residential physicals on 3/8/17. Any areas that were left blank on the physical were properly filled out. Health coordinator will be responsible to do a record review of individuals quarterly . Health coordinator will be responsible to ensure all areas of the physical are complete and no blanks are on the physical. |
04/30/2017
| Implemented |
| 6400.145(1) | REPEATED VIOLATION - 4/20/2015. The emergency medical plan did not include the source of health care to be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | All residential medical emergency plans have been updated. Attachment #6 They now include the source of Health Care to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the source of health care to be used in an emergency listed. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 |
03/08/2017
| Implemented |
| 6400.145(2) | REPEATED VIOLATION - 4/20/2015. The emergency medical plan did not the method of transportation to be used. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | All residential medical emergency plans have been updated. Attachment #6 They now include the Method of Transportation to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the method of transportation to be used in an emergency listed. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 |
03/08/2017
| Implemented |
| 6400.145(3) | REPEATED VIOLATION - 4/20/2015. The emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | All residential medical emergency plans have been updated. Attachment #6 They now include an emergency staffing plan to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the emergency staffing plan to be used in an emergency. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 |
03/08/2017
| Not Implemented |
| 6400.151(a) | Staff #3's 5/10/16 physical exam was completed late. The previous exam was completed on 7/10/13. | 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. | All staff will be notified 30 days prior to their physical date. Jaime Zaliznock, human resource manager, will notify the staff. If she has not received the staff physical by 14 days prior to the date Jaime will again notify staff. If the staff does not turn their physical in by two days prior to the physical expiration date, they will be suspended until they have their physical. Jaime Zaliznock keeps a spread sheet of the staff physical date and the date to notify the staff. (Attachment #28) |
03/09/2017
| Not Implemented |
| 6400.151(c)(2) | REPEATED VIOLATION - 4/20/2015. Staff #3's 5/12/16 tuberculin testing was completed late. The previous testing was completed on 7/12/13. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | All staff will be notified 30 days prior to their physical date. Jaime Zaliznock, human resource manager, will notify the staff. If she has not received the staff physical by 14 days prior to the date Jaime will again notify staff. If the staff does not turn their physical in, with TB testing, by two days prior to the physical expiration date, they will be suspended until they have their physical. Jaime Zaliznock keeps a spread sheet of the staff physical date, TB date and the date to notify the staff. (Attachment #28) |
04/30/2017
| Not Implemented |
| 6400.161(e) | Individual #1 was prescribed Ear Drops 6.5% on 8/25/16 to be administered for 5 days. The Ear Drops were stored in the medication box during the time of inspection. | Discontinued prescription medications shall be disposed of in a safe manner. | The health coordinator will be responsible to do a review of the MARS weekly . Health Coordinator will be responsible of disposing out of date or unused prescriptions. Compliance Specialist will review the medications quarterly during his site assessments. If any medications are found, which should be disposed of, the health coordinator will be given written warning, and if multiple warnings are given suspension and or termination will take place. |
04/30/2017
| Implemented |
| 6400.163(c) | REPEATED VIOLATION - 4/20/2015. Individual #1's 8/15/16 pyschiatric medication review was completed late. The previous was completed on 4/4/16. A psychiatric medication review was not completed for November 2016. The 8/16/16, 4/4/16, 3/7/16, 1/25/16, and 12/17/15 psychiatric medication reviews did not include the reason for prescribing the medication or the need to continue the medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | health care coordinator will be trained on the importance of a review of psychiatric medications at least every 3 months. The health coordinator will be responsible to make appointments with the prescribing physician for each individual receiving psychiatric medications. the health care coordinator will ensure that the psychiatric medications are reviewed at least every 3 months. A record review was completed on 2/28/17-3/2/17. Any individuals receiving psychiatric medications will have a review of medications every three months. |
04/30/2017
| Not Implemented |
| 6400.164(b) | Individual #1 was administered Ear Drops 6.5% on 8/28/16. The staff administering the medications did not sign off on the medication log. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | 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 trainings and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. After reviewing the MAR, she will fill out a form identifying any errors and sign/date that the review was completed. Attachment # 4 |
04/30/2017
| Not Implemented |
| 6400.168(a) | Staff #3 had a recertification date of 8/30/15 however, the last MAR review was not completed until November of 2015. Staff #3 did not complete medication administration training for 2016. Staff #3 only completd 2 MAR reviews and 1 observation. Staff #3 was passing medications without being recertified. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 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 trainings and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. After reviewing the MAR, she will fill out a form identifying any errors and sign/date that the review was completed. Attachment # 4 |
04/30/2017
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's 6/1/16 assessment did not include 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. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Not Implemented |
| 6400.181(e)(12) | Individual #1's 6/1/16 assessment did not include recommendations for training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Implemented |
| 6400.181(e)(13)(i) | REPEATED VIOLATION - 4/20/2015. Individual #1's 6/1/16 assessment did not include progress over the past year in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 6/1/16 assessment did not include progress over the past year in motor and communication skills. | 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. | Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Not Implemented |
| 6400.181(e)(13)(iii) | REPEATED VIOLATION - 4/20/2015. Individual #1's 6/1/16 assessment did not include progress over the past year in residential living. | 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. | Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Not Implemented |
| 6400.181(e)(13)(iv) | Individual #1's 6/1/16 assessment did not include progress over the past year 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. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Not Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 6/1/16 assessment did not include progress over the past year in 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. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment . The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Implemented |
| 6400.181(e)(13)(vii) | REPEATED VIOLATION - 4/20/2015. Individual #1's 6/1/16 assessment did not include progress over the past year in 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.
| A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. . The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's 6/1/16 assessment did not include progress over the past year in community integration. | 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. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment . The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Not Implemented |
| 6400.181(e)(14) | REPEATED VIOLATION - 4/20/2015. Individual #1's 6/1/16 assessment did not include his/her ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. |
04/30/2017
| Implemented |
| 6400.185(b) | Individual #1's Individual Support included an outcome to participate in community activities three times per month and lend a helping hand once per week. This outcome was not implemented. On 8/6/16, Individual #1 withdrew $40 and spent $12.97. The financial log indicated Individual #1 kept the change which totaled $27.03. According to Individual #1's Individual Support Plan, he/she can only handle $20. | The ISP shall be implemented as written. | All staff who work with individual #1 will be retrained on his ISP. They will also be trained on the importance of ensuring the ISP is implemented as written. Program Specialist will be responsible to provide retraining to all current staff and training to any future new hires. Program Specialist will also be responsible for monitoring the finical log to ensure the Individual #1 does not carry more than suggested in his ISP. Program Specialist will review monthly motes to verify that outcomes are being implemented as written. |
04/30/2017
| Not Implemented |
| 6400.186(b) | REPEATED VIOLATION - 4/20/2015. Individual #1 did not sign or date the 7/8/16 Individual Support Plan review. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Program Specialists will be retrained on the isp review and the components Compliance specialist will ensure that all ISP reviews are signed and dated by the individual. Compliance specialist will do a record review quarterly and any unsigned/date ISP reviews will be identifies and brought to the Program Specialists attention. (attachment#22) |
04/30/2017
| Implemented |
| 6400.186(c)(2) | REPEATED VIOLATION - 4/20/2015. Individual #1's 1/7/16, 4/8/16, 7/8/16, and 10/5/16 Individual Support Plan reviews did not include a review of the social, emotional, environmental needs plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | A record review was completed 2/28/17-3/2/17. The ISP reviews have been updated to include a review of the social emotional and environmental needs plan. (attachment#22) The program specialist has scheduled a meeting for the individuals team and will review his updated isp review. The new updated version of the ISP review will be sent to all team members. |
04/30/2017
| Not Implemented |
| 6400.186(e) | An option to decline the Individual Support Plan review documentation was not offered to Individiual #1's plan team members. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | A new declination form for the ISP review has been developed. All individuals team members will be asked to fill out the declination form at each ISP review. (attachment #21) |
04/30/2017
| Implemented |
| 6400.213(11) | Individual #1's 1/5/16 physical exam indicated zoloft was a contraindicated medication. The Individual Support Plan (ISP) does not mention any contraindicated medication. The ISP indicated poisons were to be locked. The 6/1/16 assessment indicated poisons were not to be locked. The ISP indicated Individual #1 should follow a high fiber diet. The 1/5/16 physical exam did not indicate any specific diet. A medical appointment from 12/7/16 indicated Individual #1 needed to increase his/her water intake, limit artificial sweetners, and limit caffiene. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | On 3/2/17, A training on content discrepancies between the Individuals records and documents was conducted by Kasey Bradley, Director. Residential Program specialist's and Health coordinators attended the training. Attachment #1. A record review for all residents of CSI was completed 2/28/17-3/2/17. The changes to the assessment, physical, and ISPs are attached Attachment #2. In order to ensure that discrepancies are not found in the future, a new compliance specialist position has been created. Andy Hamilton has been promoted to this position. Andy will do a record review every 6 months on each of the individuals CSI supports. upon completing the record review, Andy will instruct Program specialist or health coordinator on what discrepancies were found. Andy will sign that he completed the record review and date. He will also sign when he informed Program specialist. He will then follow up to make sure that the discrepancies were addressed and were no longer in the individuals records. attachment #3 A letter to individuals Supports coordinator was sent requesting that Zoloft be added to the individuals ISP under contraindicated medications. (attachment # 21) |
04/30/2017
| Not Implemented |
| 6400.216(a) | REPEATED VIOLATION - 4/20/2015. Individual #1's financial log was stored in an unlocked cabinet in the dining room. | An individual's records shall be kept locked when unattended. | All financial logs are being kept in the locked cabinet along with the MARS and Individual Records. Residential supervisor will be responsible to make sure financial records are kept in the locked area at all times when not in use. |
03/08/2017
| Implemented |