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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | The physical examination completed on 11/16/15 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Emmaus has changed their Physician's Medical Form as of 09/27/2016 to include a line that states, "Please list Medical information pertinent to diagnosis and treatment in case of an emergency:" A line is also provided for comment by the Physician. This statement is on page 2 of 2 of the document. However, for the record, Emmaus feels that our form has been utilized since 2011 and previous BHSL Inspectors did not comment on this absence. The entire form encompasses medical information that is pertinent to diagnosis and treatement in case of an emergency. This new Physician's Medical Form will be utilized throughout the agency for all of our individuals under the 6400 Regulations. [Individual name (AS 11/1/16)] will take this new form with her to her Annual Physical exam in March of 2017. [Individual name (AS 11/1/16)]'s Residential Advisor, Angie Monk, will ensure that the new updated Physician's Medical Form, revised 09/27/2016, will be used. [Individual #1's medical information was updated on 10/25/16 to included medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon completion, the Director of IDD services shall review all individuals' physical examinations to ensure all required information is included and there are not areas of required information left blank. Designated staff persons shall immediately obtain missing information from the completing physician. Documentation of reviews shall be kept. (AS 11/1/16) |
09/27/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.186(a) | Individual #1 had an ISP review completed on 12/29/14 and then again on 6/29/15. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The Residential Advisors and the Emmaus Program Specialist received a training on 9/9/2015 regarding regulation 6400.186 (a). Also, Kelly Stillwell, Director of I/DD Services notified the Emmaus Management team on 9/12/2015 regarding the CAP pertaining to 6400. 186 (a) on 9/16/2015. Also, a review of all of Emmaus' (22) individuals' ISP Reviews were reviewed by Kelly Stillwell and were correct as of 9/17/2015 date. The one above mentioned individual (#1) was informed of her ISP Review on 3/27/2015, but she incorrectly dated the ISP Review. Going forward, the Residential Advisors and Emmaus Program Specialist are aware of the Regulation 6400.186 (a) and the necessity of ISP Reviews and correct signature dates in a timely manner. |
09/21/2015
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(a) | Individual #1 was not informed of the individual's rights when admitted to the home on 3-1-14. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | Casswell ¿ 6400.31(a) ¿ Individual was not informed of her rights when admitted on 3/1/14.
What specific change will be made? CW has been a resident of Emmaus Community since 2007. Even though she lived in an un-licensed apartment, Emmaus made sure that she was informed of, and encouraged to practice all of the rights that our individuals in licensed homes enjoy. She has been signing the residents¿ rights form annually since 2007. Emmaus is confident that CW was knowledgeable of her rights upon admission to her new home, and we presented signed documentation to that effect. Emmaus now understands that any individual who moves from an unlicensed site to a licensed site will be viewed as ¿a totally new individual,¿ and he or she must re-sign the resident rights upon admission to their new home.
Who will make the change? Kristy Buczynski, Residential Program Manager / Program Specialist.
When will the change be made? This change is already in effect..
What system has been implemented to make sure that the same violation does not happen again? This violation was not made intentionally. Emmaus believed in good faith, that since CW was moving from one Emmaus home to another, that the signed residents¿ rights was sufficient. Emmaus did not view CW as an ¿entirely new individual¿ but rather one who has been informed of and practicing her rights for years. Emmaus only has one other individual living in an un-licensed home. In the event that she would move in to a licensed home, Emmaus would ensure that she re-signs her rights form. All of Emmaus¿ other residents files are in compliance, and have been for 20 years, therefore we believe that no further changes need to be made to our existing policy.
What training will be provided to staff? The Program Specialists, Kelly Stillwell and Kristy Buczynski, will be responsible for making sure that all Residential Advisors (supervisors) know and follow this policy.
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09/12/2014
| Implemented |
| 6400.213(9) | The most current ISP in the record for individual #1 is dated 7-1-13 to 6-30-14. | Each individual's record must include the following information: A copy of the current ISP. | Casswell ¿ 6400.213(9)¿ The most current ISP in the record was dated 7/1/13 ¿ 6/30/14.
What specific change will be made? All ISPs will be printed out and filed on July 1st of every fiscal year.
Who will make the change? Kristy Buczynski, Residential Program Manager / Program Specialist.
When will the change be made? This change has already been made for all Emmaus residents. All ISPs for the 2014-2015 fiscal year have been printed and filed accordingly.
What system has been implemented to make sure that the same violation does not happen again? This violation was not made intentionally. Emmaus has always printed out the most recent ISP after the annual meeting / revisions have been made, and staff reads and signs off on it. In 20 years of being licensed, Emmaus has never been cited on this regulation, nor were we ever informed that everyone must have the ISP cover page and service detail page printed on July 1st of every year in order for it to ¿count¿ as the ¿most recent¿ ISP due to fiscal year dates and service detail rates updates. Emmaus will, from now on, print everyone¿s entire ISP every July 1st so that the fiscal year, all program content, and the service detail information is current as of each new fiscal year.
What training will be provided to staff? The Program Specialists, Kelly Stillwell and Kristy Buczynski, will be responsible for making sure that all Residential Advisors (supervisors) know and follow this policy.
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09/12/2014
| Implemented |
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