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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1 had a gynecological examination on 05/20/19, and then again on 11/18/20. There is no documentation from a licensed physician recommending no or less frequent than annual gynecological examinations. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 1. On 4/24/2021, as recommended by the Licensing, Health/IDD Manager met with Individual #2 to provide training and discussion on the importance of maintaining health by attending all doctor appointments. Individual #2 agreed and happy that with completed Covid-19 Vaccination, individual #2 is more protected.
2. Health/IDD Manager had set up Gynecological exam appointment for Individual #2 for 5/11/2021.
3. On 5/7/2021, CCO will submit Individual #2¿s acknowledgement on the importance of attending all doctor appointments and out reminder and Therap schedule for Gynecological exam appointment for 5/11/2021. [Training for Individual #1 about Health Care Needs, Outlook reminder, and Therap schedule verified on 5/21/21. Agency Medical Appointment Policy and Procedure, dated 4/26/21, verified on 5/21/21. DPOC by HDKP, HSLS, on 5/21/21]. |
05/07/2021
| Implemented |
| 6400.151(a) | Direct Service Worker #1 had a physical examination completed on 09/17/18, and then again on 12/16/20. | 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. | 1. On 4/26/2021, CEO sent out a memo to Direct Service Worker #1 and all TLHHC¿s employees, notifying the related inspection results and the importance of complying in providing biennial TB Test and a Physical by the date notified by HR, to pay attention to HR¿s communications, and to reach out when staff encounters problem in scheduling doctor appointment.
2. CCO will submit staff¿s signed acknowledgment on 5/8/2021. [Documentation of staff acknowledgement, occurring on varied dates, verified on 5/21/21. HR Work Planner and Outlook reminder verified on 5/21/21. DPOC by HDKP, HSLS, on 5/21/21]. |
05/08/2021
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1 had a Tuberculin skin test by Mantoux method on 10/11/18, and then again on 12/18/20. | 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. | 1. On 4/26/2021, CEO sent out a memo to Direct Service Worker #1 and all TLHHC¿s employees, notifying the related inspection results and the importance of complying in providing biennial TB Test and a Physical by the date notified by HR, to pay attention to HR¿s communications, and to reach out when staff encounters problem in scheduling doctor appointment.
2. CCO will submit staff¿s signed acknowledgment on 5/8/2021. [Documentation of staff acknowledgement, occurring on varied dates, verified on 5/21/21. HR Work Planner and Outlook reminder verified on 5/21/21. DPOC by HDKP, HSLS, on 5/21/21]. |
05/08/2021
| Implemented |
| 6400.15(b) | The agency completed a self assessment on 12/16/20 and on 03/16/21, but did not use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | 1. On 4/22/2020¿s Team Meeting, CEO decided that agency will conduct self-inspection to all houses except Logan Ferry using Self-Inspection in Appendix in RCG. On 4/23/2021, CEO, CCO, Program Specialist, QA/CO, and Health/IDD Manager met to go over each section of the RCG and Self-Inspection. Team learned that they are more items added. However, we gladly have documentations from 2019 pertaining to individual rights.
2. Self-inspection using new tools were completed:
a. On 4/30/2021 at Dorothy House and Greenfield House
b. On 5/1/2021 at Green Tree House and Highland House
c. On 5/2/2021 at Braun House, Delmont House, and Rubco House
3. On 5/3/2021, during team meeting, was the finalization of Self-Assessment Completion.
4. CCO will submit the completed self-inspection on 5/7/2021
5. CCO will submit all the meeting signature sign-in sheets and meeting minutes on 5/7/2021. |
05/07/2021
| Implemented |
| 6400.46(b) | Direct Service Worker #1 was trained by a fire safety expert on 01/29/20, and then again on 03/13/21. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | 1. On 4/23/2021, CCO created Relias Annual January Fire Safety Training. The training is refresher training on TLHHC¿s Fire Safety Training and Emergency Evacuation Procedures. This training plan also includes an Expert Fire Safety Training. The training will be given annually in January and will no longer be included in Quarter 1 Annual Training. New hires will still be given Fire Safety Training.
2. On 4/26/2021, CEO sent out a memo to Direct Service Worker #1 and all TLHHC¿s employees, notifying the related inspection results and the importance of complying in completing training on time.
3. CCO will submit screenshot of Relias Annual January Fire Safety Training and staff¿s signed acknowledgment on 5/8/2021. [Documentation of Relias Fire Safety training added to electronic learning system verified 5/21/21. Staff acknowledgement of fire safety training requirements, occurring on varied dates, verified 5/21/21. DPOC by HDKP, HSLS, on 5/21/21]. |
05/08/2021
| Implemented |
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