| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | REPEAT-09/21/21-Upon requesting financial documents from Staff #1 for Individuals 4, 5 & 6, he emailed "There is no current financial ledger in their money bags so I created the one I submitted to you to document the amounts of money currently in the bags. I also could not located December ledgers for all three, I will go back to the house and see if they are there." | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | : Each individuals financial ledger will be audited by the Associate Director to ensure completion and accuracy of the financial ledger and funds available. |
03/09/2022
| Not Implemented |
| 6400.22(e)(2) | Individual #4's financial ledger lists a beginning balance of $25 on November 21 and does not contain a December 21 Ledger. The January 22 beginning balance is $0.
Individual # 5's financial ledger lists a beginning balance of $105 on November 21 and does not contain a December 21 Ledger. The January 22 beginning balance is $112.89
Individual # 6's financial ledger lists a beginning balance of $40 on November 21 and does not contain a December 21 Ledger. The January 22 beginning balance is $0. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | Each individuals financial ledger will be audited by the Associate Director to ensure completion and accuracy of the financial ledger and funds available. |
03/09/2022
| Not Implemented |
| 6400.43(b)(1) | The CEO failed to implement policies and procedures including the implementation of COVID Visitor safety protocols. On 12/22/21 when asked why staff were not taking temperatures of visitors, Staff #1 emailed "we do not have documented visitor temperature checks" and their Infectious disease policies "do require updates to be compliant with current recommendations".
The CEO failed to ensure that Plans of Corrections for previous violations including individual's laying in their own urine were implemented. When asked for documents which were to be implemented to prevent neglect including health and safety checklists, weekly inspection forms and home inspection forms, Staff # 1 emailed on 12/16/21 "I searched our Brazil home which houses all of the permanent records and none of the health and safety checklists, weekly inspection forms, or home inspection forms were on site. The previous Program Manager maintained a large white binder with all of the completed forms in question and when she left the agency, she physically showed me were they were kept and completed documents." Health and Safety Checklists were to be completed by staff every shift to ensure the health and safety of the individuals at all of the homes.
A November 17, 2020 Incontinence and Health Care Policy was implemented which required "All Residential Program Workers will be trained on the Incontinence and Health Care Policy as well as individual tracking sheets for any individual identified as experiencing incontinence". Individual incontinence tracking sheets were not completed as policy indicated. "Residential Program Managers/Program Specialist will monitor individual tracking sheets to ensure compliance and adjust monitoring times as well as ongoing health care concerns related to incontinence." There is no documentation that supervisory monitoring of tracking sheets was completed.
Staff #18 stated during a witness interview on 12/17/21 that "They were told that they are not allowed to discuss the consumers during shift change. They were told to write it down instead of verbalizing in front of consumers." When staff # 1 was asked for the staff communication logs for home # 1 and home # 2, he emailed on 12/22/21 "I uploaded the past three entries in the log kept at home # 1 (salix). It appears that there are only two entries in that log since 09/04/21 I could not locate any log at home # 2 and the staff I have spoken to indicated that they are not aware of a staff log" Staff # 17 reported during a witness interview on 12/22/21 that the home has a communication log but she is not sure what it is used for and was never trained on using the log".
Staff #17 stated during a witness interview on 12/22/21 that "When I first started working at home # 2 I worked 4-12 shift. Forms ran out and they needed more things for the books. I reached out to supervisor and never got forms. Other staff reached out to Supervisor as well. This happened in the Beginning of September/October of this year (2021)." When asked which forms were missing, she stated " All of them. Shower Charts, Sleep Charts, Every form that is in there and Documentation was just not done, because there is only so much that staff could do." | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Immediate corrections include termination of the CEO responsible for lapses in oversight in relation to citations of current inspection. A CEO has been immediately appointed, in order to execute responsibilities outlined in chapter 6400 regulations. AUCP is also in the process of hiring a permanent CEO who will be responsible for chapter 6400 compliance as well as oversight in implementation of corrective actions identified in this report. The interim CEO has implemented a Covid Health Screening form for staff and visitors when entering a home. Also a new daily care sheet was created to reflect, incontinence, sleep chart, meals and calories, eliminations, shift notes, issues on shift and who it was reported to. |
03/09/2022
| Not Implemented |
| 6400.43(b)(4) | - The aforementioned and following violations in this Licensing Inspection Summary demonstrate that there was a CEO failure to ensure compliance with Chapter 6400 regulations. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | Immediate corrections include termination of the CEO responsible for lapses in oversight in relation to citations of current inspection. A CEO has been immediately appointed, in order to execute responsibilities outlined in chapter 6400 regulations. AUCP is also in the process of hiring a permanent CEO who will be responsible for chapter 6400 compliance as well as oversight in implementation of corrective actions identified in this report. Ongoing corrective action includes the development of an audit tool to ensure compliance with 6400 regulations. 6400 regulations and the 6400 RCG will be used as a guide to develop the audit tool. The audit tool is being created by the Associate Director which will be approved by the CEO to be implemented. |
03/09/2022
| Not Implemented |
| 6400.73(a) | The outside stairs leading to the basement door includes six steps at the home. There is no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The maintenance will acquire outside service to secure a handrail by 3/1/22. After an estimate is made it will be submitted to the Financial department for approval. |
03/09/2022
| Implemented |
| 6400.76(a) | Individual #6's bed mattress was stained in urine. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The associate director had the bed mattress replaced by maintenance. |
03/09/2022
| Implemented |
| 6400.77(b) | The first aid kit did not contain tweezers during the walk through on 12/16/21 | REPEAT-10/20/20- A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The field manager will ensure all first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. |
03/09/2022
| Implemented |
| 6400.80(a) | There was a 3X3 area of leaves and debris at the home's entrance to the basement door. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Associate director had the leaves and debris was moved from the home basement entrance by maintenance. |
03/09/2022
| Implemented |
| 6400.103 | The emergency evacuation documentation for individuals #4, #5, and #6 are not current. The documentation states a former address in Johnstown. The "emergency evacuation" book at the home also included non current individual plans and physicals for individual #4. #5, and #6. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| A new emergency evacuation document was created to include individual and staff responsibilities, means of transportation and an emergency shelter location. The Program Specialist will be trained on their responsibilities for updating any corrections to the Emergency Evacuation Document such as address change or relocation shelter change. |
03/09/2022
| Not Implemented |
| 6400.141(c)(6) | Individual # 6 received a TB test on 03/12/18 and not again until 02/08/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Program Specialist is reviewing each individual for annual medical dates. All individuals¿ medical appointments not attended in the last 12 months will be scheduled and entered in the automated reminder system by the Program Specialist for tracking. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system quarterly for completion and accuracy. In conjunction with the automated reminder system an auditing tool is being created by the Associate Director to ensure compliance with 6400 regulations. The associate director will train the Program Specialist on the automated reminder system and auditing tool to assure medical appointments are completed on the due date. The Program specialist will also be trained on completion of annual medical forms by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.141(c)(9) | Individual # 4 received a prostate examination on 01/08/19 and not in 2020 as the 12/21/20 physical exam reads 01/08/19 as the last prostate exam. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The Program Specialist is reviewing each individual for annual medical dates. All individuals¿ medical appointments not attended in the last 12 months will be scheduled and entered in the automated reminder system by the Program Specialist for tracking. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system quarterly for completion and accuracy. In conjunction with the automated reminder system an auditing tool is being created by the Associate Director to ensure compliance with 6400 regulations. The associate director will train the Program Specialist on the automated reminder system and auditing tool to assure medical appointments are completed on the due date. The Program specialist will also be trained on completion of annual medical forms by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.141(c)(14) | REPEAT-09/21/21-Individual # 6's Physical exam dated 02/08/21 does not include information pertinent to diagnosis in case of an emergency. The space is left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist is reviewing each individual for annual medical dates. All individuals¿ medical appointments not attended in the last 12 months will be scheduled and entered in the automated reminder system by the Program Specialist for tracking. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system quarterly for completion and accuracy. In conjunction with the automated reminder system an auditing tool is being created by the Associate Director to ensure compliance with 6400 regulations. The associate director will train the Program Specialist on the automated reminder system and auditing tool to assure medical appointments are completed on the due date. The Program specialist will also be trained on completion of annual medical forms by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.141(c)(15) | REPEAT-09/21/21-Individual #6's Physical exam dated 02/08/21 does not include special instructions for diet. The space was left blank. | The physical examination shall include:Special instructions for the individual's diet. | The Program Specialist is reviewing each individual for annual medical dates. All individuals¿ medical appointments not attended in the last 12 months will be scheduled and entered in the automated reminder system by the Program Specialist for tracking. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system quarterly for completion and accuracy. In conjunction with the automated reminder system an auditing tool is being created by the Associate Director to ensure compliance with 6400 regulations. The associate director will train the Program Specialist on the automated reminder system and auditing tool to assure medical appointments are completed on the due date. The Program specialist will also be trained on completion of annual medical forms by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.142(a) | Individual # 5's dental examination dated 02/10/21 was not signed or dated by a dentist. Individual # 4's last dental examination was 09/09/20 and not signed by the dentist. There is no dental examination for 2021. | 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. | The Program Specialist will review all individuals ISPs and train all staff on current planned or prescribed treatment for each individual requested by the health service. The training will be documented and submitted to the HR Department to maintain, and a hard copy will be printed and placed in the permanent chart housed at the individuals home. |
03/09/2022
| Not Implemented |
| 6400.142(e) | Individual # 6 had a dental examination on 03/23/21 with a follow up appointment scheduled for 10/06/21 at 11:00 am. There is no documentation that this follow up appointment occurred on 10/06/21. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The Program Specialist will review all individuals ISPs and train all staff on current planned or prescribed treatment for each individual requested by the health service. The training will be documented and submitted to the HR Department to maintain, and a hard copy will be printed and placed in the permanent chart housed at the individuals home. |
03/09/2022
| Not Implemented |
| 6400.144 | REPEAT-10/20/20, 09/21/21-Individual # 6 had a physician's visit on 07/09/21 due to blood in his urine reported at the day program. He was diagnosed with Hematuria and recommended increased fluids and a return to his PCP within one week. When asked about the follow up appointment, Staff # 1 reported that "For July, His next appointment and I believe what was to be the follow up occurred on 07/26 although the appointment summary is not specific. I could not find any supporting documentation that an earlier appointment was made and cancelled by either our agency or the doctor's office so I'm not sure why it was not completed prior to 07/16 recommendation. I found no supporting documentation yet regarding staff being informed to increase his fluids." | 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.
| The Program Specialist will review all individuals ISPs and train all staff on current planned or prescribed treatment for each individual requested by the health service. The training will be documented and submitted to the HR Department to maintain, and a hard copy will be printed and placed in the permanent chart housed at the individuals home. |
03/09/2022
| Not Implemented |
| 6400.181(a) | An assessment for 2020 was not provided by the agency for Individual # 4. Confirmation of an annual assessment being completed can not be determined for Individual # 5 due to no date on the assessments provided | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individual¿s permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. |
06/09/2022
| Not Implemented |
| 6400.181(d) | Individual #6's assessment is not signed or dated by the Program Specialist. Individual # 5's assessment was not signed by the Program Specialist. A hand written note reads 2021. | The program specialist shall sign and date the assessment. | Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individual¿s permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.181(e)(7) | Individual #6's assessment (no date or signature) reportedly emailed to the SC on 03/10/21 does not indicate if he can sense or move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individual¿s permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.216(a) | Medical appointment cards were displayed on the refrigerator for individuals #4, #5, and #6. | REPEAT-10/20/20- An individual's records shall be kept locked when unattended. | All of the individuals information was removed from areas that were not locked and placed in secured locations. |
03/09/2022
| Implemented |
| 6400.20(b) | The last quarterly review of incidents was completed for October 2020- December 2020. Staff # 1 emailed "Since the previous directors departure in early 2021, it has not yet been updated for the current fiscal year." | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | The interim CEO will review of all incident events from 2021 will be done analyzed by 2/28/22 |
03/09/2022
| Not Implemented |
| 6400.20(c)(1) | The last quarterly review of incidents was completed for October 2020- December 2020. Staff # 1 emailed "Since the previous directors departure in early 2021, it has not yet been updated for the current fiscal year." The number of incidents was not identified | The home shall identify and implement preventive measures to reduce: The number of incidents. | The interim CEO will review of all incident events from 2021 will be done analyzed by 2/28/22 |
03/09/2022
| Not Implemented |
| 6400.20(c)(2) | The last quarterly review of incidents was completed for October 2020- December 2020. Staff # 1 emailed "Since the previous directors departure in early 2021, it has not yet been updated for the current fiscal year." The severity of the risk associated with incidents was not identified | The home shall identify and implement preventive measures to reduce: The severity of the risks associated with the incident. | The interim CEO will review of all incident events from 2021 will be done analyzed by 2/28/22 |
03/09/2022
| Not Implemented |
| 6400.20(c)(3) | The last quarterly review of incidents was completed for October 2020- December 2020. Staff # 1 emailed "Since the previous directors departure in early 2021, it has not yet been updated for the current fiscal year." The likelihood of incidents recurring was not identified. | The home shall identify and implement preventive measures to reduce: The likelihood of an incident recurring. | The interim CEO will review of all incident events from 2021 will be done analyzed by 2/28/22 |
03/09/2022
| Not Implemented |
| 6400.20(e) | The last quarterly review of incidents was completed for October 2020- December 2020. Staff # 1 emailed "Since the previous directors departure in early 2021, it has not yet been updated for the current fiscal year." The home did not monitor incidents and take actions to mitigate and manage risks. | The home shall monitor incident data and take actions to mitigate and manage risks. | The interim CEO will review of all incident events from 2021 will be done analyzed by 2/28/22 |
03/09/2022
| Not Implemented |
| 6400.31(a) | No key for the basement was available at the home site. This hindered the access to the basement for individual who reside at the home, including individual's #4, #5, and #6. Licensing staff need to wait until the provider's maintenance staff came to the home with the key to open the basement door. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.) | The key to the basement door was made available to the house and location was communicated to the staff members. |
03/09/2022
| Not Implemented |
| 6400.34(a) | REPEAT-09/21/21-Individual # 6 signed an individual rights statement on 12/31/20. There is not date of signature for the 2021 Individual Rights statement provided. Individual # 5's Individual Rights statement is signed but not dated. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | : Each individuals permanent charts were checked for current signed and dated Individual Rights. The individuals who did not have a current signed and dated individual rights form were informed of their individual rights and signed a new form which was placed in their permanent chart. |
03/09/2022
| Not Implemented |
| 6400.45(d) | Individual # 4's ISP requires a staffing ratio of 1:3, Individual # 5's ISP requires a staffing ratio of 1:2, Individual # 6's ISP requires a staffing ratio of 1:2. Staff schedules indicated that the home regularly schedules only one staff for overnights when ratio's require at least two staff when all three individuals are in the home. The staff schedule only lists one person per shift every Saturday and Sundays from October 2021-Dec 2021. When inquired about the reason for only one staff and maintaining ratio's, Staff # 1 emailed that he "believes it was an SC oversight when they moved from Ashdale and the accurate ratio is 3:1." | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | The associate director assessed all individuals ISPs to check for accuracy in ratio mentioned on 2/2/22. The associate director also sent an ISP correction form to each individuals supports coordinator on 2/2/22. |
03/09/2022
| Not Implemented |
| 6400.46(b) | Staff # 17 received Fire Safety Training on 11/14/20 and did not receive fires safety training in 2021. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Human Resources will ensure that all current residential staff working in the homes are trained. HR will ensure that the subjects listed are included in the training.
General fire safety
Tour of Facility
Evacuation procedures
Responsibilities during fire drills
Designated meeting place outside the building of fire safe area
Smoking safety procedures if individuals or staff smoke at the home.
Use of Fire Extinguishers, smoke detectors and fire alarms and
Notification of the local fire department as soon as possible after a fire is discovered |
03/09/2022
| Not Implemented |
| 6400.50(a) | REPEAT-10/20/20-Staff #7 has a discrepancy in training hours. Her 11/03/21 training log lists 14 hours. Her sign in sheets only list the time for 11/03/21 as 8:30-12:30 training. Staff # 14's training log does not include specific lengths of training for each topic listed as being trained. The training log lists 12/17/20 as "CLA Orientation" lasting 14 hours. However, the sign in sheets for Orientation day 1 list 8:30 am with end of 3:30 pm with a 12pm-1pm lunch. Orientation day 2 lists 8:30 am end 4pm with 12pm-1pm lunch. The sign in sheets for orientation do not match the training log dates or length of trainings. Staff #15's training logs do not include specific lengths of training for each topic listed as being trained. The sign in sheets of orientation dates are 02/22, 23/21 with the training log listing 02/24/21 totalling 14 hours of training. Staff # 16 signed an orientation sheet on 10/04/21 for training ranging from 8:30am-3:30pm. The training log does not list an orientation training for 10/04/21.Staff #12 signed a training log on 08/10/21 which included confidentiality, consumer control, Instrumental activities of daily living, Recognizing changes in the consumer that needs to be address, basic infection control, universal precautions, Handling emergencies, documentation, recognizing and reporting abuse or neglect, dealing with difficult behaviors, bathing, grooming, dressing, hair skin and mouth care, assistance with ambulation and transferring, meal preparation and feeding, toileting, assistance with self administration of medication, specialized care and TB Education. There is no length of training on the signature form. Her training log lists Heart Saver First Aid and CPR as the only training received on 08/10/21.
Staff # 4's training log lists CLA Orientaiton as 14 hours of training on 09/09/21 as well as First Aid/CPR EX training on 09/09/21 for 4 hours totalling 18 hours of training on 09/09/21. The sign in sheets for 09/09/21 only list FA/CPR training from 08:30AM-12:00PM. The Training logs and Sign in Sheets do not match. In a witness statement provided by Staff # 4 on 12/17/21, she stated "they never properly trained me on the books, I read ISP's and answered questions···I've never been trained in Home # 1 or Home #2. I've been made to work at home #1 even after asking to be trained, I was never trained on the consumers individually."
Staff # 11 stated in a witness interview on 12/16/21 that "There was not training on the books". | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | HR will audit all residential program staff training records to assure compliance associated with the chapter 6400 regulations. If a staff person is out of compliance the HR department will pull them from working in the homes until compliance is met. |
03/09/2022
| Not Implemented |
| 6400.52(c)(6) | - Staff # 2-12 worked at the home as per staff schedules and documents provided. These staff do not have training sheets which indicate that they were trained in the ISP's for the Individual # 4, Individual # 5 and Individual # 6. Staff #4 stated in an investigatory witness statement on 12/17/21 that "I've never seen a menu or been told of any dietary restrictions. They told me when hired to make what I want". Staff #4 also stated "I've been made to work at home even after asking to be trained, I was never trained on the consumers individually. I never knew that some even had diet restrictions." Staff # 11 stated in a witness statement on 12/16/21 that she was "unaware of any special diets until a couple of days ago". | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | The Program Specialist will review all individuals ISPs and train all staff on current planned or prescribed treatment for each individual requested by the health service. The training will be documented and submitted to the HR Department to maintain, and a hard copy will be printed and placed in the permanent chart housed at the individuals home. |
03/09/2022
| Not Implemented |
| 6400.162(a) | Staff # 2's Medication Administration Annual Practicum lists a completion date of 03/04/20. The form does not have a Trainer signature nor and indication of if he was Certified or Failed to Certify. There are no Trainer signatures nor dates on subsequent Annual Practicum forms submitted for dates after 2020. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Current medication passers will be trained on the protocol and policy around medication administration. |
03/09/2022
| Not Implemented |
| 6400.162(b)(1) | Staff #2 was not trained in passing medication as per violation 162a. Staff # 2 passed medications for Individual # 4 on 09/20&25/21, 11/20-22/21 and 12/02,04,06/21. Staff # 2 passed medications for Individual # 6 on 09/04,06,11,17,24,25,26/21, and 10/02,03,09,13,14,16,20,26,27/21, 11/06, 20, 21, 22, 24, 29, 30/21, and 12/01,02,04,05,06,07,10, 12, 15, 16/21. | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | Current medication passers will be trained on the protocol and policy around medication administration. |
10/09/2022
| Not Implemented |
| 6400.166(b) | Individual # 6 is prescribed Doculiquid 50 mg/5ml and Lactulose 50LN 10gm/5ml at 9pm. There are no initials on the MAR that the dosage was given on 09/03/21. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Current medication passers will be trained on the protocol and policy surrounding failure to administer a medication by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.182(a) | Individual # 6's ISP dated 06/22/21 states that he is residing in an apartment at Ashdale. Individual #6 does not live in an apartment and now lives in a home with a date effective of 05/07/21 in the ISP. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | Immediate corrections include hiring a Program Specialist. The Program Specialist is reviewing each individuals¿ assessments, medical appointments and ISP for any inconsistencies. If an inconsistency is found the Program Specialist will fill out an ISP correction form found on AUCP shared drive and will send it to the Associate Director and Supports Coordinator to have the ISP reflect the correct information. The Program Specialist will then print out a hard copy and place it in the individual¿s permanent chart. An automated reminder system is also being created to monitor all annual dates for each individual. The automated reminder system is being created by a consultant and will be maintained by the Associate Director. The CEO will check the automated reminder system for completion and accuracy. The Associate Director will train the Program Specialist on the automated reminder system to assure assessments are completed on the date due by. The Program specialist will also be trained on completion of annual assessments by the Associate Director. |
03/09/2022
| Not Implemented |
| 6400.182(d) | Individual # 6 did not participate in the ISP plan development meeting held on 03/10/21. The only signatures of attendees are the Service Coordinator, AUCP Program Specialist and Day Program Specialist | The individual and persons designated by the individual shall be involved and supported in the initial development and revisions of the individual plan. | The associate director will train the program specialist of the required documentation needed from an individuals isp meeting which will include that the Program Specialist will ensure all attendees at the meeting sign the sign in sheet provided by the support coordinator and are accounted for. |
03/09/2022
| Not Implemented |
| 6400.183(a)(3) | A direct care staff person did not attend the ISP plan development meeting held on 03/10/21 for Individual #6. The only signatures of attendees are the Service Coordinator, AUCP Program Specialist and Day Program Specialist. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | The associate director will train the program specialist of the required documentation needed from an individuals isp meeting which will include that the Program Specialist will ensure all attendees at the meeting sign the sign in sheet provided by the support coordinator and are accounted for. |
03/09/2022
| Not Implemented |