| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The 8/14/14 fire letter only mentions Individual #1, #2 & #3 requiring verbal prompts. The fire drill logs for 4/21/15 states Individual # 2 required physical assistance and on 1/18/15 Individuals #2 & #3 required physical assistance to evacuate drill the fire drill. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter was sent to the fire company reflecting Individual #2 needs to sometimes needing physical assistance. It also reflects Individuals #1 and #3 current levels of assistance as well. These letters will be completed yearly and upon any changes with the individual as the arise if their ability to evacuate during drills changes. |
09/28/2015
| Implemented |
| 6400.112(g) | The fire drill held on 7/8/14 did not contain the time the fire drill was conducted. | Fire drills shall be held on different days of the week and at different times of the day and night. | A training was completed on 6/17/2015 informing those responsible for conducting fire drills to ensure all requirements are completed. On 9/22/2015 a new form was designed due to the old one being very congested with information. This form is more precise for the information needed to be completed and more spread out. Making it easier to read. these trainings, a blank new fore drill form and the most recent fire drill using this form will be submitted. |
09/22/2015
| Implemented |
| 6400.143(a) | Individual #1 refused the GYN appointments in 2013 & 2014. There was no refusal plan in the record or recorded attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | An updated letter from Individual's OBGYN has stated that this individual can refuse an appointment and be seen again in the next year. |
07/01/2015
| Implemented |
| 6400.151(a) | Staff person #1 was late on the bi-annual physical exam: 2/6/12- 10/19/14. | 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. | Plan of correction: These non-compliances were found during our self-audit in February of 2015. Since then, we have implemented the following: Shifted job duties: The HR employee now responsible for tracking physicals and TBs has direct access to our current electronic database (prior to this, the person responsible for tracking did not have direct access to the database because of IT difficulties). This employee has also added reminders to her google calendar to look at physical/TB dates and send out notices to employees 3-4 months before they are due. The employee also keeps a paper list on her desk where she documents correspondence she has had with staff regarding their appointments, etc. This will allow all members of HR to pull down the same data and will allow further oversite of the physical/TB due dates. HR members complete filing at least twice per month and now also audit the paper physicals/TBs each time for a double-check.
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03/01/2015
| Implemented |
| 6400.151(c)(2) | Staff person #1 was late with the bi-annual Tuberculin skin test- 2/6/12-10/19/14. | 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. | Plan of correction: These non-compliances were found during our self-audit in February of 2015. Since then, we have implemented the following: Shifted job duties: The HR employee now responsible for tracking physicals and TBs has direct access to our current electronic database (prior to this, the person responsible for tracking did not have direct access to the database because of IT difficulties). This employee has also added reminders to her google calendar to look at physical/TB dates and send out notices to employees 3-4 months before they are due. The employee also keeps a paper list on her desk where she documents correspondence she has had with staff regarding their appointments, etc. This will allow all members of HR to pull down the same data and will allow further oversite of the physical/TB due dates. HR members complete filing at least twice per month and now also audit the paper physicals/TBs each time for a double-check.
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03/01/2015
| Implemented |
| 6400.163(c) | The psychiatric medication reviews on 10/7/14 & 11/11/14 for Individual #1 did not include dosages. It listed the medication Perphenazine 4mg; it should have stated 4 mg BID. Also listed was Lorazepam .5mg when it should have stated .5mg in the a.m. and 1.5 mg in the p.m. | 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. | A new medication review form was created to show accurate dosage and times of the medications prescribed. All Supervisors and Program Specialists were trained on this form on 9/22/2015. A copy of the training, new form and the most current individual that has utilized this form since it was created will be submitted. |
09/22/2015
| Implemented |
| 6400.181(e)(3)(ii) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Communication. It was exactly the same as 2014. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Communication. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency, |
09/28/2015
| Implemented |
| 6400.181(e)(13)(ii) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Motor and Communication Skills. It was exactly the same as 2014. | 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 Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Motor and Communication Skills. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(iii) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Activities of residential living. It was exactly the same as 2014. | 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 Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Activities in residential living. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(iv) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Personal adjustment. It was exactly the same as 2014. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Personal Adjustment. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(v) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Socialization. It was exactly the same as 2014. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Socialization. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(vi) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Recreation. It was exactly the same as 2014. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Recreation. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.181(e)(13)(vii) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Financial independence. It was exactly the same as 2014. | 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.
| Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for Financial Independence. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/0205
| Implemented |
| 6400.181(e)(13)(viii) | The 4/9/15 annual assessment for Individual #1 did not contain progress in the area of Managing personal property. It was exactly the same as 2014. | 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. | Program Specialists were retrained on 9/28/2015 to ensure that yearly assessments are updated to include progress over the past year for managing personal property. They will ensure that new things the individual was able to accomplish, work on, and successes are added and updated yearly to reflect progress for that year. the most current assessment will be submitted by the agency. |
09/28/2015
| Implemented |
| 6400.186(c)(1) | The ISP review 5/12/15 for Individual #1 did not contain a review of the progress during the prior 3 months for the out comes of Cooking and Social. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | All Supervisors and Program Specialists were retrained on June 1, 2015, to ensure all information from the monthly is transferred to the quarterly to show outcomes and community activities in their entirety. Both Program Supervisors and Program specialists are responsible to ensure this is completed during quarterly reviews. A quarterly for individual #1 will be submitted to show this was been remedied and a training form that all supervisors and Program Specialists have been retrained. |
06/01/2015
| Implemented |
| 6400.186(c)(2) | The following ISP reviews for Individual #1 did not review the Dental Plan, Dental Desentization or Community inclusion- 5/12/14, 8/11/14, 11/12/14 and 2/11/15. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | All Supervisors and Program Specialists were retrained on June 1, 2015, that the Individuals' are having their dental plan and dental desentization reviewed. Both Program Supervisors and Program specialists are responsible to ensure this is completed monthly. A monthly and the dental plan will be submitted to show the remediation. |
06/01/0205
| Implemented |
| 6400.211(b)(1) | The emergency contact information for Individual #1 was not kept current. The name on the emergency sheet listed Individual #1's deceased mother as the person to contact in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | All supervisors and program Specialists were retrained on the importance to updating emergency information for all individuals served and their contacts. this was completed on 9/23/2015. Individual #1 emergency medical information was updated on 6/1/2015. |
06/01/2015
| Implemented |
| 6400.211(b)(3) | The emergency t information for Individual #1 was not kept current. The name to give consent for emergency medical treatment listed Individual #1's deceased mother. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | All supervisors and program Specialists were retrained on the importance to updating emergency information for all individuals served and their contacts. this was completed on 9/23/2015. Individual #1 consent to treatment and personal information sheet was updated on 6/1/2015. |
06/01/2015
| Implemented |