| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The provided financial data for Individual #2 did not include reconciled bank statements that determine dates and amounts of deposits and withdrawals | 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. | Holcomb is in the process of reviewing the client funds policy and updating the information. A new process will be in place by 07/01/2022 which will include monthly reports as a part of the electronic record so information can be checked by all. |
08/31/2022
| Implemented |
| 6400.62(a) | Individual #1's plan indicates they do not understand security precautions, that poisons are kept locked up, and that the agency uses non-toxic cleaning supplies to further mitigate risk. Poisonous cleaning chemicals were found in several unlocked areas around the house. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisonous materials were not locked at the time of inspection. No residents were present in the home during the inspection. Staff will be retrained on the hazardous materials by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.64(b) | Pest control traps were found beneath the kitchen sink. | There may not be evidence of infestation of insects or rodents in the home. | There is no infestation present in the home. The trap contained no bugs or rodents. |
07/01/2022
| Implemented |
| 6400.66 | The exterior light outside of the basement washroom was non-operative. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Basement light was fixed by Holcomb maintenance on 05/09/2022. |
05/09/2022
| Implemented |
| 6400.72(a) | The basement bathroom window was not securely screened at time of inspection; the window could open but its screen was not in place. The second floor bathroom's window screen was loose, resting against the interior of the window rather than being secure in the window frame. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The basement bathroom window and screen were repaired by Holcomb maintenance on 05/09/2022. |
05/09/2022
| Implemented |
| 6400.72(b) | The kitchen window was non-operative; it could not be opened. | Screens, windows and doors shall be in good repair. | The kitchen window crank was repaired by Holcomb maintenance on 05/09/2022. |
05/09/2022
| Implemented |
| 6400.76(c) | Individual #1's armchair in the living room is partially damaged, with portions of fabric on both arm rests ripped away, exposing the material underneath. Individual #1's bedroom dresser is also missing all knobs on its second drawer, and one knob from its third drawer down. | Furniture shall be comfortable and home-like. | The armchair was purchased by the individual's family. They have been notified that another chair is needed to meet state requirements. We are currently waiting on the family to purchase the chair. |
07/01/2022
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | A mirror was installed in the individual's bedroom by Holcomb maintenance on 05/12/2022. |
05/12/2022
| Implemented |
| 6400.110(e) | The smoke detector in the attic was not connected to the other smoke detectors in the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The smoke detector is connected to the other detectors in the home but was malfunctioning. The smoke detector has been replaced by Holcomb maintenance. Repair appointment is scheduled for 06/03/2022. |
06/03/2022
| Implemented |
| 6400.141(c)(3) | Immunization information was not found in the contents of the current physical for Individual #2. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | All immunization records have been uploaded to the electronic record on 05/09/2022. |
05/09/2022
| Implemented |
| 6400.141(c)(6) | The date of the most recent TB test was not found in the contents of the physical for Individual #2. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | PPD completed 08/04/2021 and uploaded to the EMR on 05/09/2022. |
05/09/2022
| Implemented |
| 6400.141(c)(10) | There is no indication as to whether Individual #2 is free of communicable diseases | 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. | An appointment has been made for the individual to see his PCP where he will be cleared for communicable diseases. The appointment is 06/10/2022. |
07/01/2022
| Implemented |
| 6400.142(a) | The available medical information did not contain any dental care data for Individual #2. | 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. | A dental appointment has been made for the individual. The appointment is 06/22/2022. |
07/01/2022
| Implemented |
| 6400.144 | Several medications listed on Individual#2's MAR were missing from their medication kit. Artificial tears has been signed for by staff in their MAR from 5/1/22 -- 5/4/22 at 8AM and 5/1/22 -- 5/2/22 at 8PM (5/3/22 at 8PM was missing a signature); however, the bottle of artificial tears was found empty, and was dated 1/13/2020. Ear drops 6.5% sol. were also missing from the kit, and had been signed on the MAR by staff from 5/1/22 -- 5/3/22. Further, both the April and May 2022 MARs for the individual indicate the ear drops are to be administered weekly on Wednesdays, but the MAR was signed by staff daily from Monday, 4/25/22 -- Thursday, 4/28/22 and again on Saturday, 4/30/22, in addition to the 5/1/22 -- 5/3/22 signatures described above. As medications were missing and documentation on the reviewed MARs was inconsistent and sometimes reflected divergence from written prescription orders, pharmaceutical services are not being fully provided. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The medications for the individual have been audited by the AD. Two medications were not present. Eye drops were renewed by the PCP and are being given as prescribed. The ear drops were not renewed by the prescriber due to the individual needing a new appointment. The individual completed the appointment and now has the drops that are being given as prescribed. |
07/01/2022
| Implemented |
| 6400.145(1) | Individual #2's record did not contain an emergency medical plan | 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. | The home's emergency medical plan has been updated to include the individual. The individual recently moved to the site and no update had been done. House Management will be retrained on the completion of emergency plans upon admission. Training will be completed by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.181(d) | Individual #2's assessment is not signed by the program specialist. | The program specialist shall sign and date the assessment. | The program specialist will be retrained on the completion of assessments by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.181(e)(14) | Individual #2's assessment does not report surety of the individual's ability to swim. It reports his own statement of "enjoying swimming", but this is not proof of ability. The lifetime medical statement, and the provided ISP, both report that he cannot 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. | The individual's assessment has the following verbage: INDIVIDUAL IS ABLE TO TEMPER WATER ON HIS OWN. INDIVIDUAL IS AWARE OF THE DANGERS ASSOCIATED WITH WATER, AND IS ABLE TO BATHE INDEPENDENTLY. INDIVIDUAL REPORTS THAT HE CAN NOT SWIM, AND THEREFORE SHOULD BE MONITORED AROUND BODIES OF WATER, SUCH AS A POOL OR LAKE. |
07/01/2022
| Implemented |
| 6400.183(2) | There is no record that Individual #2 has an individual plan team | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual to increase community involvement, including volunteer or civic-minded opportunities and membership in National or local organizations as required under § 6400.188 (relating to provider services). | The individual has a treatment team in place. They did not receive the most recent assessment however, they do meet frequently to discuss the individual's care. A copy of the ISP sign in sheet will be added after each ISP meeting. The House Manager will be retrained on the importance of including the sign in sheet by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.195(c) | The restrictive procedure plan for Individual #2 outlines for knives/sharps and van seating were not found in the provided BSP. | The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months.
| Restrictive procedures were not approved for use with the individual. The BSS developed a plan with proposed restrictions that was put into place by a Division Manager who is no longer employed by Holcomb. The restrictions were immediately removed upon discovery on 05/04/2022. The plan was removed from the home and is currently pending HRT approval. |
07/01/2022
| Implemented |
| 6400.24 | Under the 1970 Controlled Substances Act, all Class C medications must be double locked and counted at each administration of the medication. The individual's April 2022 controlled substance log tracks the pill count for their haloperidol medication inconsistently and unclearly: per their April and May 2022 MARs, 4 pills are to be administered daily -- 1 at 8AM (10mg); 1 at 4PM (5mg); and 2 at 8PM (2mg each). One log provided listed a contradictory prescription order, indicating the haloperidol was to be taken in 5 mg dosages 3 times daily; that log often tracks the administration of 3 pills daily in April 2022, until 4/26/22, when the pill count jumped down from 36 pills remaining to 19. The May 2022 controlled substance log was more complete and consistent. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The home was using two different versions of the controlled substance count sheets. The home has since discontinued the use of the original sheet and the second version of the sheet is now being used in the home. The staff will be retrained on doing the controlled substance counts by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.163(a) | Individual #2's fluticasone prescription nose spray did not have its complete pharmacy label. Two bottles of the medication were in the kit: one bottle had a sticker indicating the individual's name and gave administration instructions, and listed the date it was filled; it contained no pharmacy or prescriber information. The second bottle's sticker listed the individual's name, but no instructions, pharmacy, or prescriber information. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The pharmacy has been contacted and advised that the full prescription label is needed on all medications. Staff will be reminded to not throw away the original packaging of the medication if it contains the full label by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.163(f) | Individual #3's prescription Mupirocin ointment was found stored in the house's first aid kit with a loose cap; the bottle was sticky to the touch, indicating the ointment had leaked out onto the tube's exterior. | Prescription medications stored in a refrigerator shall be kept in an area or container that is locked. | The medication was removed from the first aid kit and returned to the proper location. Staff will be retrained on keeping all medications together by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.166(a)(13) | Individual#2's MAR was missing signatures for medication administrations for many medications on several dates and times: ammonium lactate 12% cream -- 5/3/22 at 8PM; benztropine -- 5/3/22 at 8PM; clonidine -- 5/3/22 at 8PM; cyproheptadine -- 5/3/22 at 8PM; gabapentin -- 5/3/22 at both 4PM and 8PM; polyethylene glycol powder was missing signatures for all of May 2022 to date; and senna -- 5/3/22 at 8PM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The staff did give the medication as prescribed but forgot their password to the electronic MAR. The program will develop a secondary procedure for staff to follow in the event they are unable to access the electronic MAR by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.167(a)(4) | Individual#2's prescription Senna has been administered at the wrong time. The written order on the MAR and on the prescription blister pack indicate two tablets are to be taken by mouth every evening, but staff have administered it every morning instead. 4 sets of tablets were missing from the blister pack, whereas only 3 should have been missing at time of inspection, indicating the dose had been given early on 5/4/22. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Staff did give the medication at the wrong time. Staff in the home will be retrained on the 5 rights of medication administration by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.181(f) | There is no indication that Individual #2's assessment was given to the individual plan members at least 30 calendar days prior to the meeting, or that it was given to them at all. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The individual's team was not given the assessment 30 days prior to the ISP. The Program Specialist will be retrained on the importance of sending the assessment to the team 30 days prior to the team meeting by 07/01/2022. |
07/01/2022
| Implemented |
| 6400.184(4) | There is no record of Individual #2's individual plan process occurring at timely intervals | The individual plan process shall: Occur timely at intervals, times and locations of choice and convenience to the individual and to persons designated by the individual. | The individual's record contains records of all prior ISP team meetings occurring. No other treatment team meeting information was requested during the virtual audit. |
07/01/2022
| Implemented |
| 6400.192 | There is no record in Individual #2's file regarding the staff persons who may authorize the use of RPs, and a mechanism to monitor and control the use of RPs | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | Restrictive procedures were not approved for use with the individual. The BSS developed a plan with proposed restrictions that was put into place by a Division Manager who is no longer employed by Holcomb. The restrictions were immediately removed upon discovery on 05/04/2022. The plan was removed from the home and is currently pending HRT approval. |
05/04/2022
| Implemented |
| 6400.194(a) | There is no documentation in Individual #2's record confirming an assembled HRT; there is no documentation confirming the credentials of the team; there is no documentation of the individuals comprising the HRT; there is no record of HRT meetings being held | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | Holcomb does not have a HRT and uses Delware County's HRC for restrictive plan approvals. Per regulations, providers are able to use County HRC instead of having their own. However, Holcomb is reconsidering forming an HRT due to having more individual's who require restrive procedures. The HRT for Holcomb will be formed by 07/01/2022 and able to review plans. |
07/01/2022
| Implemented |
| 6400.195(a) | There is no record in Individual #2's file of an HRT review of the restrictive procedures prior to their use. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Restrictive procedures were not approved for use with the individual. The BSS developed a plan with proposed restrictions that was put into place by a Division Manager who is no longer employed by Holcomb. The restrictions were immediately removed upon discovery on 05/04/2022. The plan was removed from the home and is currently pending HRT approval. |
07/01/2022
| Implemented |
| 6400.195(b) | There is no record in Individual #2's file of HRT meetings being conducted every six months (only a training record was provided dated 3.13.22) | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Restrictive procedures were not approved for use with the individual. The BSS developed a plan with proposed restrictions that was put into place by a Division Manager who is no longer employed by Holcomb. The restrictions were immediately removed upon discovery on 05/04/2022. The plan was removed from the home and is currently pending HRT approval. |
07/01/2022
| Implemented |
| 6400.196(a) | There is no record in Individual #2's file of staff training specific to the restrictive procedures outlined in the available information from the BSP. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Restrictive procedures were not approved for use with the individual. The BSS developed a plan with proposed restrictions that was put into place by a Division Manager who is no longer employed by Holcomb. The restrictions were immediately removed upon discovery on 05/04/2022. The plan was removed from the home and is currently pending HRT approval. |
07/01/2022
| Implemented |
| 6400.213(1)(i) | The photo in the record belonging to Individual #2 is not dated. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The individual now has a current picture. |
07/01/2022
| Implemented |