| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The Agency failed to write a summary of correction for:Individual Rights- 31(a) and 31(b)
ISP Development- 182(d)(4)
Individual Records- 213(4) | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Delta will complete a self- assessment and will write a complete summary of all corrections made. This summary will be completed by the Regional Director and kept on file at Delta for at least 1 year.
Going forward, each home's Program Coordinator or Associate Director will complete the self-assessment prior to the required due date and will be signed off by the Regional Director to ensure completion and corrections are completed by the required due date. The Regional Director will write a complete summary of all corrections made based on the results of the self-assessments. |
02/01/2020
| Implemented |
| 6400.62(c) | In the kitchen cabinet under the sink a water bottle with an unknown yellow liquid was found. | Poisonous materials shall be stored in their original, labeled containers. | Unknown substance was immediately removed from under the kitchen sink at the time of the site visit on 9/11/19. A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.62(d) | There was Food stored in the kitchen cabinet under the sink with unknown substance and dawn dish liquid (Capri suns, apple juice, and punch), and corn oil. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Unknown substance was immediately removed from under the kitchen sink on 9/11/19.
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.67(a) | There were several Scuff marks on the wall in the living room area. | Floors, walls, ceilings and other surfaces shall be in good repair. | The wall was repainted on 9/16/19. (Attachment # 1)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.82(e) | The Hall bathroom did not have a non-slip surface in the shower or a bath mat. | Bathtubs and showers shall have a nonslip surface or mat. | A non-slip mat was purchased and placed in the bathroom on 9/11/19. A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
| 6400.142(a) | Individual #1's record did not have documentation for a current dental exam. | 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. | Standard dental exam care is unable to be completed by the dentist. Individual #1 dental needs can only be completed under sedation, but had not been cleared by her PCP or a cardiologist, a requirement of the dentist. Individual #1 went to her PCP again on 11/11/19. Another ECG was completed on 11/18/19. The results were normal. (Attachment # 2) Physical packet and ECG results will be given to PCP to complete so dental care under general sedation can be scheduled and completed. |
03/01/2020
| Implemented |
| 6400.181(e)(1) | Individual #1's annual assessment completed on 12/18/18 did not include Strength, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Assessment template was redone on 10/1/19 to include strengths needs and preferences. (Attachment # 3) Individual #1's assessment will be redone on the new template and sent to her team by 12/18/19 for approval and sign offs. Going forward all assessments will be completed on the new template by the Program Specialists. |
12/12/2019
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's annual assessment completed on 12/18/18 did not include Progress over the last 365 calendar days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Assessment template was redone on 10/1/19 to include progress and growth in the area of health. (Attachment # 3) Individual #1's assessment will be redone on the new template and sent to her team by 12/18/19.
Going forward all assessments will be completed on the new template by the Program Specialists. |
12/18/2019
| Implemented |