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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home completed on 11/16/22 did not assess compliance with the following regulations: 6400.163g, 6400.163h, 6400.165a -- 6400.165g, 6400.166a1 -- 6400.166a5, 6400.168a, and 6400.168b. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. |
10/01/2023
| Implemented |
| 6400.15(c) | (Repeated Violation - 7/11/22) The self-assessment for the home completed on 11/16/22 did not include a written summary of corrections for the following violations: 6400.21a -- 6400.21c, 6400.46b, and 6400.46d. | 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.
| Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. |
10/01/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's July 2017 financial log indicated that $1.00 was lost. A staff member adjusted the amount of $63.43 to $62.43 with "lost $1.00" on 7/20/18. Individual #2's cash on hand should have been 110.45. The actual cash on hand was 110.38 | (2) Disbursements made to or for the individual.
| 22 (d) (2):
Immediate: Individual #2 was reimbursed $1.08 and the Individual¿s financial ledger reflects reimbursement.
Global Immediate: Program Managers, or appropriate designee, of each program shall review each Individual¿s ledgers between the months of October 2017 and August 2018 to ensure that no discrepancies are noted between the ledgers and receipts, and that the current balance is correct. This review shall take place on or before 9/30/2018 and actions taken to address any discrepancies, as applicable, immediately upon discovery. Documentation of the review and findings shall occur via confirmation email to Associate Director of Operations by each Program Manager.
Program Coordinators shall complete a review of each Individual¿s finances and financial records on file at each program during each month¿s monitoring and documentation of review kept on file, including how each discrepancy was addressed, as applicable. Retraining (provided by Program Coordinator or Associate Director) shall occur immediately with the Program Manager at the time of noted discrepancies, as applicable, and documentation of retraining shall be kept on file.
Director of Operations shall provide retraining to members of the Finance Team responsible for oversight of Individual¿s finances, to include the expectation of reviewing each entry on the ledger and comparing it to each receipt to ensure accuracy of each entry, and additionally reviewing each month¿s balance transfer to the following month to ensure accuracy at the time of each Individual¿s bi-monthly cash and checking accounts audit completed by a member of the Finance Team. Retraining will also include the expectation that the full bi-monthly audit period be fully reviewed and that all cash/checking balances are accurate, with any discrepancies addressed immediately, as applicable. Retraining will occur on or before 9/17/2018 and shall be documented.
Global Preventive: The Director of Finance and Director of Operations shall review and update current policies and procedures related to Individual finances on or before 9/30/2018 to ensure that specific requirements for recording and documenting discrepancies noted in Individual¿s finances and financial records are clearly defined, including appropriate measures to address any discrepancies immediately upon discovery by any Team Member, Program Manager, Program Coordinator and/or Finance Team Member. Retraining shall occur for all Direct Support Professionals, Program Managers, Program Coordinators and other appropriate members of the Leadership and Finance Teams, with the expectation that all policies and procedures related to Individual¿s finances are adhered to at all times. A Care Tracker message shall be sent to all members of the Team who have access to the system and otherwise, documentation of retraining shall be in the form of a typed memo. All retraining shall be confirmed through signed acknowledgement by each Team Member (electronic signature acceptable). Retraining shall occur on or before 10/15/2018 with all members of the team as stated above. |
10/15/2018
| Implemented |
| 6400.141(c)(8) | Individual #2's mammogram was completed on 2/3/17 and not again until 5/2/18. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | 141 (c) (8):
Immediate: Individual #2 received her mammogram on 5/2/2018 and results were obtained for her record by the Program Coordinator on 8/22/2018.
Global Immediate: Program Managers, or appropriate designee, shall confirm compliance with required appointments for each Individual, including assurance that all appropriate time frames as specified in 6400 Regulations and/or as specified by each Individual¿s physician(s) have been adhered to. Program Manager or designee shall review each Individual¿s records and confirm via email to Associate Directors of Operations on or before 9/23/2018, to include any steps taken to address identified areas of non-compliance, as applicable. Documentation of review and supporting documents shall be kept on file.
Global Preventive: The Associate Director of Operations provided retraining to the Program Managers on 8/23/2018 regarding the requirement to adhere to all medical appointment required time frames as specified in 6400 Regulations and/or by each Individual¿s physician(s). Additionally, Program Managers received retraining on a medical communication log implemented in February 2018 where communications with medical or other providers shall be logged on behalf of Individuals to keep a record of any unusual circumstances related to scheduling and/or attending scheduled medical appointments (i.e. provider reschedules due to insurance approval process). |
09/23/2018
| Implemented |
| 6400.213(11) | Individual #2's physical exam included allergies to penicillin, paxil, dust mites, cigarette smoke, cat dander, Haldol, tegretol, Prozac, phenobarbital. Her assessment included allergies to IV versed, rifampin, Depakote. These were not included on the physical or ISP. The ISP indicated seasonal allergies. This was not indicated on the physical exam. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | 213 (11):
Immediate: Individual #2¿s support team has a meeting scheduled for 8/30/2018 to compile a comprehensive list of all allergies and sensitivities that are listed across documents to provide the primary care provider to determine definitive allergies. The Program Specialist and Nursing Consultant will ensure that all content in the Individual¿s record is consistent in addition to contacting the pharmacy to ensure the Individuals¿ record contains the comprehensive list of allergies. Each Team Member working with or on behalf of Individual #2 will then review and sign the most current list of allergies to acknowledge their understanding on or before 9/23/2018.
Global Immediate: Program Managers shall compile a list of documents on or before 9/23/2018 where each Individual¿s allergies are listed to perform a cross reference to evaluate for discrepancies. Should a discrepancy occur they will contact the Individual¿s primary care physician to evaluate the list for accuracy immediately and update the Individual¿s record. Documentation of such conversations shall be recorded in the Individual¿s record and communicated to Team Members working with or on behalf of Individual(s). Documentation of cross reference of allergy information within each Individual¿s record shall be kept on file.
Global Preventive: The Program Specialist Program Coordinator shall develop and implement an ISP update/content review checklist on or before 10/23/2018 to verify consistency of content across each Individual¿s records at the time of ISP and other documentation updates, which shall be utilized during quarterly assessments, and shall include allergy information. Training for Program Managers and Program Specialists on this form will occur on or before 11/23/2018, at which time this practice shall be fully implemented. Documentation of training shall be kept on file. |
11/23/2018
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(i) | Staff #1 had First Aid/CPR training on 1/30/13 and not again since. She was due for recertification on 1/30/15. Annual inspection was on 2/18/15. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 was trained on 3/10/2015. Adminstrative assistant reviewed all employee records to verify compliance. A tracking system will be developed and maintained. |
| Implemented |
| 6400.112(c) | A fire drill was conducted on 3/9/14 and the time it took for individuals to evacuate was not recorded. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program coordinator of each program will verify that subsequent fire drills (since 2/20/2015) include information that verify evacuation time. Care tracker documentation will verify that all supervisors and program coordinators are trained on fire drill explectations and documentation. |
| Implemented |
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