| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | On 2/7/16 staff recorded on Individual #1's financial ledger that $18.76 was the balance of the account. The actual balance on the account on 2/7/16 should have been $18.67. The financial ledgers for Individual #1 have been off by $.09 from 2/7/16 to present. | (2) Disbursements made to or for the individual.
| Who: All residential staff that counts money. Additionally, the APC that checks house accounts on a weekly basis and the Administrative Assistant (5th floor Admin staff) will also be responsible to ensure that the house accounts are correct.
What: Ensure that the individual¿s house accounts are accurate.
When: Residential staff ¿ daily during wallet checks. APC and Administrative Assistant review house accounts weekly.
How: Residential staff should be verifying the amount of the receipts (for either additions or subtraction¿s) when completing wallet checks. APC will utilize an excel spread sheet to verify amounts. Administrative Assistant will check accounts and verify accuracy but utilizing a system to ensure that the amount present is accurate based on receipts and any request for additional funds.
Attachments:
¿ Signature sheets showing staff was trained in POC (attachment # 18)
¿ Copy of excel spreadsheet that was implemented that is utilized by the APC (attachment # 19)
¿ Copy of Policies and Procedures (attachment # 20)
¿ RPS meeting agenda (attachment #11) |
09/19/2016
| Implemented |
| 6400.67(a) | The hand rail on the front porch ramp was completely detatched from the ramp. There was approximately a 4 foot chunch of cement missing from the front porch walkway. This missing chunk of cement was thus allowing the front porch to sink into the accessible ramp next to the front porch. | Floors, walls, ceilings and other surfaces shall be in good repair. | Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3)
¿ Email from property manager stating that the work is scheduled to be completed. (attachment #21)
¿ Completed Administrative Regulation Monitoring form that was updated.(attachment # 5 ) |
11/30/2016
| Implemented |
| 6400.74 | The garage steps were not equiped with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3 )
¿ Email from property manager stating that the work is scheduled to be completed. (attachment # 21)
¿ Completed Administrative Regulation Monitoring form that was updated.(attachment # 5) |
11/30/2016
| Implemented |
| 6400.103 | The emergency evacuation procedure did not include individual and staff responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Who: Assistant Director of ID Services
What: Updated the form to include all regulatory requirements.
When: After form was found to be out of compliance with regulations.
How: Form was updated after licensing. All staff and individuals were trained in their responsibilities in the event that an evacuation must occur at one of the group homes. A copy of the form that was individualized for each individual, was placed in the individual¿s records at the home.
Attachments:
¿ Copy of the Emergency Relocation Plan for each individual (attachment # 1)
¿ Signature showing that all staff and all individuals were trained in their responsibility (attachment # 2 ) |
09/19/2016
| Implemented |
| 6400.144 | Individual #1 was to have monthly counseling sessions completed. He/She had an appointment on 10/21/15 and not again until 2/2/16. He had a counseling appointment on 1/20/16 however staff forgot to take Individual #1. Individual #1's dentist and psychiatrist recommended, on 12/21/15 and 9/23/15 respectively, that he/she use Biotine for dry mouth due to psychotropic medications. Biotine was not available in the home, nor were staff aware of the recommendations. | 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.
| Who: All residential staff
What: Ensure that all planned or provided health services are arranged for or provided.
When: ongoing
How:
¿ Retraining all staff on ensuring recommended health services are implemented
¿ Updated schedule form that is reviewed by PC to ensure adequate coverage and that all appointments are listed and assigned to specific staff
¿ Disciplinary protocol implemented to be utilized with any staff that misses an appointment
¿ Dental Hygiene plan implemented for each individual along with signature sheet to ensure all staff are trained on current dental plans.
Attachments:
¿ RPS meeting Agenda (attachment #11)
¿ Copy of individual #1 12/21/15 dental and 9/23/15 psychiatric paperwork including a letter from LPN and disciplinary protocol that the LPN will follow if an appointment is missed in the future (attachment #15)
¿ Dental hygiene plans (attachment #16)
¿ Updated schedule form that is signed (attachment #17)
¿ Staff assigned to run appointment (attachment #17) |
09/19/2016
| Implemented |
| 6400.168(e) | Staff #1 failed the initial medication administration training course and required remediation. The documentation of the dates and information reviewed for remediation was not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | Who: Training Coordinator (Primarily) and all Medication Administration Trainers.
What: Complete paperwork to show remediation, including the dates.
When: As needed - when staff fail part of their medication training and require remediation.
How: Documentation will be kept with the staff¿s paperwork. This paperwork will include the dates that staff received remediation.
Attachments:
¿ Form that was created to keep track of the dates of remedial training, including the signature sheet showing that all staff members who are Medication Administration Trainers were trained in the new paperwork. (attachment# 24 A)
¿ Copy of staff¿s training that required remediation due to not passing part of her training and new form that was implemented (attachment 24 B). |
09/19/2016
| Implemented |
| 6400.181(e)(10) | Individual #1's 4/4/16 assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that the life time medical history is included with the assessment.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: Please note that the Assessment always contained a Lifetime Medical History, and the assessment clearly stated that the life time medical history was done with the assessment, but at the time of licensing, the manner in which we file our paperwork showed that the assessment was filed in 2 separate sections. Additionally, the letter sending out the assessment did not state that the lifetime medical history was ¿part of the annual assessment. Plan of correction was to update the cover letter sending the assessment to the team members now states: ¿Enclosed, please find a copy of (individuals¿ name) Annual Assessment that include the Lifetime Medical History that was completed on (date).
Attachments:
¿ Copy of updated cover letter that shows changes. (attachment # 13)
¿ Copy of annual assessment that shows that annual assessment states that ¿Although the complete medical history may be separated from the annual assessment, the complete medical history is the last part of the annual assessment. The reason the information is separate is because the information is sent to the individual¿s Primary Care Physician for review¿ (attachment # 13 ) |
09/19/2016
| Implemented |
| 6400.181(e)(13)(ii) | REPEAT from 3/25/15 annual: Individual #1's 4/4/16 assessment did not include progress and current level 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. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulatory information in the assessment includes progress and current level of skills.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: PC¿s were retrained and requirements of regulations were reviewed. As far as progress and current level of skills, progress should be noted in detail. If progress was not made, but the current skill level stayed the same, you must document why the present skill level stayed the same and what was implemented to help the individual to increase their skills, knowledge, etc.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of individual¿s assessment that was fully completed by the PC and address motor and communication skills (attachment #13) |
09/19/2016
| Implemented |
| 6400.181(e)(13)(iv) | REPEAT from 3/25/15 annual:Individual #1's 4/4/16 assessment did not include progress and current level 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. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulatory information in the assessment includes progress and current level of skills.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: PC¿s were retrained and requirements of regulations were reviewed. As far as progress and current level of skills, progress should be noted in detail. If progress was not made, but the current skill level stayed the same, you must document why the present skill level stayed the same and what was implemented to help the individual to increase their skills, knowledge, etc.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of individual¿s assessment that was fully completed by the PC and address motor and communication skills (attachment #13) |
09/19/2016
| Implemented |
| 6400.181(e)(13)(v) | REPEAT from 3/25/15 annual:Individual #1's 4/4/16 assessment did not include progress and current level in socialization. | 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. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulatory information in the assessment includes progress and current level of skills.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: PC¿s were retrained and requirements of regulations were reviewed. As far as progress and current level of skills, progress should be noted in detail. If progress was not made, but the current skill level stayed the same, you must document why the present skill level stayed the same and what was implemented to help the individual to increase their skills, knowledge, etc.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of individual¿s assessment that was fully completed by the PC and address motor and communication skills (attachment #13) |
09/19/2016
| Implemented |
| 6400.181(e)(13)(ix) | REPEAT from 3/25/15 annual:Individual #1's 4/4/16 assessment did not include progress and current level 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. | Who: Program Coordinators (Specialists by regulations)
What: Ensure that all regulatory information in the assessment includes progress and current level of skills.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: PC¿s were retrained and requirements of regulations were reviewed. As far as progress and current level of skills, progress should be noted in detail. If progress was not made, but the current skill level stayed the same, you must document why the present skill level stayed the same and what was implemented to help the individual to increase their skills, knowledge, etc.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of individual¿s assessment that was fully completed by the PC and address motor and communication skills (attachment #13) |
09/19/2016
| Implemented |
| 6400.181(f) | Individual #1's 4/4/16 assessment was not sent to his behavior support team. His assessment was sent on 10/5/15 and behavior support did not end until 12/4/15. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Who: Program Coordinator (Specialist by Regulations)
What: Ensure that the assessment is sent out to ALL team members.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: All records were checked. Individual¿s #1 assessment was updated to show corrections were made on other areas of non-compliance. Additionally, the cover letter was updated to include the behavioral support team on all assessments that are sent out, and the quarterly review reports if the behavioral support team stated that they wanted to receive the written reports.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Updated copy of Individual¿s #1 assessments to show corrections and to show that cover letter has been updated (attachment #29) (please note that individual no longer receives behavioral support.) |
09/19/2016
| Implemented |
| 6400.183(5) | The protocol to address Individual #1's social, emotional, and enviornmental needs that was included in his/her Individual Support Plan (ISP), did not include a protocol to address behaviors of physical aggression and stealing money. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Who: Program Coordinator (Specialist by Regulations)
What: Ensure that the SEEN plan includes behaviors that the individual displays.
When: as needed for the SEEN plan, but quarterly for the quarterly review reports.
How: SEEN plan was modified in the assessments and in the quarterly review reports. Prior, the SEEN plan only addressed psychiatric symptoms and that behaviors were listed separately.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Updated assessment to show change and update quarterly review report (attachments # 13 and # 14) |
09/19/2016
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) indicated that he/she was unable to handle any amount of funds. According to staff, they give Individual #1 up to $50 to handle independently. | The ISP shall be implemented as written. | Who: Program Coordinator (Specialist by regulations)
What: Ensure that the individual ISP are implemented as written.
When: ongoing
How: The Coordinator will ensure that the ISP is correct and implemented as written. After the ISP is finalized, you should review the entire ISP to ensure that all information is correct and written as discussed at the ISP meeting. In the event that you find an error or additional information needs to be documented, you will email the Supports Coordinator. A copy of the email will be put with the ISP.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of email sent to SC asking for corrections (attachment #23) |
09/19/2016
| Implemented |
| 6400.186(a) | The program specialist is not completing the Individual Support Plan (ISP) reviews for Individual #1. A direct support staff, without the program specialist qualifications, is completing the reviews. | 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. | Who: Program Coordinator (Specialist by regulations)
What: Complete the quarterly review of the ISP¿s in whole
When: ongoing ¿ every 3 months after the start date of an individual¿s ISP
How: The Program Coordinator (Specialist by regulations) must complete all aspects of the quarterly reviews. At this time, the monthly outcome progress form has been revised. The RPS will complete the monthly outcome progress form. The Program Coordinator will utilize this form, in addition to the other paperwork that is completed on a daily basis and speak with staff that work with the individual to complete the quarterly review form in whole.
Attachments:
¿ Signature sheet from RPS meeting (attachment #10)
¿ RPS meeting Agenda (attachment #11)
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of quarterly review that was fully completed by the PC only (attachment #14) |
09/19/2016
| Implemented |
| 6400.186(b) | The Individual Support Plan (ISP) review that was completed for Individual #1 on 2/5/16 was not dated by Individual #1. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Who: Program Coordinator (Specialist by regulations)
What: Ensure that the individual signs and dates the quarterly review report.
When: ongoing ¿ every 3 months after the start date of an individual¿s ISP
How: The quarterly review form was updated. The signature sheet was discontinued. The Program Coordinator, Specialist by regulations, will sign and date the last page of the report. The individual will also sign and date the last page of the report. The PC CANNOT mail the report to the team until the report is reviewed with the individual.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of quarterly review that was fully completed by the PC only (attachment #14) |
09/19/2016
| Implemented |
| 6400.186(c)(1) | The 5/9/16 Individual Support Plan (ISP) review for Individual #1 did not review their participation and progress towards their "meal planning" outcome. The outcome started in March of 2016 and the review only stated that "he did well the first month." | 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. | Who: Program Coordinator (Specialist by regulations)
What: Ensure that progress is noted in detail.
When: ongoing ¿ every 3 months after the start date of an individual¿s ISP
How: Program Coordinators were retrained in the expectations of their jobs in documenting progress on a quarterly review report. The Program Coordinator will ensure that progress or lack of progress is clearly documented. This includes documenting the number of attempts, the number of successes, and any concerns.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of quarterly review that was fully completed by the PC only (attachment #14) |
09/19/2016
| Implemented |
| 6400.186(d) | The 5/9/16 Individual Support Plan (ISP) review was sent to team members on 5/9/16 however the review was not completed with Individual #1 until 5/23/16. The 11/3/15 ISP review was sent to team members on 11/3/15 but not reviewed with Individual #1 until 11/15/15. The ISP reviews are complete when they are reviewed with the individual. ISP reviews should be sent to plan team members after completion. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Who: Program Coordinator (Specialist by regulations)
What: Ensure that the individual signs the quarterly review report before it is send out to the team.
When: ongoing ¿ every 3 months after the start date of an individual¿s ISP
How: The quarterly review form was updated. The signature sheet was discontinued. The Program Coordinator, Specialist by regulations, will sign and date the last page of the report. The individual will also sign and date the last page of the report. The Program Coordinator CANNOT mail the report to the team until the report is reviewed with the individual.
Attachments:
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of quarterly review that was fully completed by the PC only (attachment #14) |
09/19/2016
| Implemented |
| 6400.216(a) | Individuals #1-#3's daily logs from 2014-2016 were unlocked and accessible in filing cabinets in the basement. | An individual's records shall be kept locked when unattended. | Who: All staff within the residential program.
What: Ensure that all records are locked when unattended.
When: ongoing
How: All staff were once again retrained in regulation Chapter 6400. 216 regarding access to records. The Quality Manager verified with all homes that the area in which records are stored are locked. Filing cabinets were purchased for 2 homes due to the cabinets that were at the home being damaged.
Attachments:
¿ Signature sheets of staff showing retraining (attachment #3 ).
¿ RPS meeting agenda (attachment #11)
¿ Email showing that filing cabinets were purchased for 2 homes. (attachment #22) |
09/19/2016
| Implemented |