| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(b) | The medication errors described in 6400.167a1 are not reported in the department's incident management system. | Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home.
| After further review of the file, it was discovered that medications that were not documented in the MAR as being administered on 11/8/23, 11/25/23 and 3/6/24, were in fact not administered by house staff as Individual #1 was away with family during that time. Please see documentation of the leave in the supporting documentation folder titled Leave Doc#1 and Leave doc #2. There was no medication error, there was a documentation error in the staff failing to mark leave in the MAR. |
12/20/2024
| Implemented |
| 6400.64(a) | At the time of the 10/16/24 inspection, there was dirt and leaf litter accumulated between the windows and storm windows.
At the time of the 10/16/24 inspection, there was an accumulation of dirt and lint to the right of the clothes dryer. | Clean and sanitary conditions shall be maintained in the home. | The windows were cleaned and cleared of all debris on 11/4/24. Please see the photographs of the cleaned windows in the supporting documents folder titled clean window 1, clean window 2. |
12/20/2024
| Implemented |
| 6400.66 | At the time of the 10/16/24 inspection, there was no light above the exterior exit from the laundry room to the rear porch. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A light was placed above the lower-level exit from the laundry room on 11/4/24. Please see a photograph of the light turned on above the door titled laundry exit. |
12/20/2024
| Implemented |
| 6400.67(b) | At the time of the 10/16/24 inspection, the first-floor bathroom shower had a rust like substance on the drain. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The first-floor bathroom tub was cleaned and rust-like substance removed on 11/4/24. Please see a photograph of the bathtub in the supporting documents folder titled Tub. |
11/21/2024
| Implemented |
| 6400.72(b) | At the time of the 10/16/24 inspection, there was a broken windowpane in the lower-level bathroom.
At the time of the 10/16/24 inspection, the interior door leading to the garage was broken and splintered at the top edge. | Screens, windows and doors shall be in good repair. | The broken windowpane was replaced on 11/1/24. See the photograph of the repaired window in supporting documentation titled lower-level bathroom pane.
The interior door leading to the garage was replaced on 11/4/24. See photograph of the repaired door in the supporting documents folder titled Door 1 and Door 2. |
12/20/2024
| Implemented |
| 6400.113(a) | Individual #2 temporarily moved into the home on 10/30/23, with the move being made permanent on 12/11/23. Individual #2 did not receive fire safety training at this home until 4/20/24. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Individual #2 was trained after the move in date. Please see documentation of another Individual who moved in over the past year that shows proper and timely fire safety training held on the same date as move in on 6/17/24.The documentation can be found in the supporting documents folder titled FST day 1. |
12/20/2024
| Implemented |
| 6400.151(a) | Staff person #6 had a physical examination on 12/13/21 and not again until 2/14/24.
Staff person #11 was hired on 6/10/24. This staff person has not had a physical examination completed.
Staff person #15 had a physical examination on 9/16/22 and not again until 10/12/24. | 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. | Staff #6 and their Program Supervisor were retrained by the Program Manager in the requirements of this regulation and how to track the due date for employee physicals on 10/17/24.A copy of the training sign in sheet has been included as supporting documentation.
Staff #11 did have a physical exam that was dated 5/16/24 however it did not include a TB test. On 10/28/24 Staff #11 received a physical exam which included having a TB test. See physical exam form.
The Program Director and the HR Director met with the temp agency on 10/30/24 to clarify the information that a physical needs to contain in order to meet this regulation and ensure that these requirements are met for any future temp staff.
Staff #15 and their supervisor were retrained by the Program Director on the requirements of this regulation and how to track the due date for employee physicals on 11/19/24. A copy for the training sign in sheet is attached in the Pinetree Way folder titled staff physical training. |
12/20/2024
| Implemented |
| 6400.151(c)(2) | Staff person #11 was hired on 6/10/24. This staff person has not had a tuberculin test completed. | 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. | Staff # 11 had a TB test completed on 10/28/24. See physical form with documentation of TB test.
The Program Director and the HR Director met with the temp agency on 10/30/24 to clarify the need for temp staff to have a TB test that meets the requirements of this regulation. |
12/20/2024
| Implemented |
| 6400.46(b) | Staff person # 10 completed fire safety training on 8/21/23 and not again until 9/1/24.
Staff person #13 has not completed fire safety training since 9/2/22.
Staff person #15 completed fire safety training on 6/4/23 and not again until 10/8/24. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff member #10 completed the Fire Safety training course on 9/1/24.
Staff member #13 completed the Fire Safety training course on 11/19/24
Staff member #15 was away on leave when the Fire Safety training came due. They completed the course upon their return to work on 10/8/24. |
12/20/2024
| Implemented |
| 6400.46(c) | Staff person #11 was hired on 6/10/24 and first worked with individuals on 7/7/24. This staff person did not complete first aid training until 10/2/24. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Staff person #11 completed First Aid Basics training in Relias on 10/02/2024, then received CPR/First Aid training completed by the temp agency on 11/05/2024. A copy of staff #11's CPR and First Aid Training certificate has been included as supporting documentation. |
12/20/2024
| Implemented |
| 6400.46(d) | Staff person #6 has not completed training in CPR and First Aid since 2/21/22.
Staff person #15 completed CPR and First Aid training on 3/12/22 and not again until 4/4/24. | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #6 completed CPR and First Aid training on 10/16/24 and received retraining on the requirement of this regulation by the Program Manager on 10/17/24. A copy of staff #6's CPR and First Aid Training certificate has been included as supporting documentation.
Staff member #15 was retrained by the Program Director on the importance of completing the required training prior to the due date. The staff was reminded of the Relias prompts that come to them at least 2 months prior to the due date. |
12/20/2024
| Implemented |
| 6400.51(a)(1) | Staff person #6 only completed 7.5 hours of annual training in training year July 1, 2023 through June 30, 2024. Additionally, this staff person did not complete training in the areas covered in 6400.52c1 through 6400.52c4. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Staff #6 received retraining on the requirement of this regulation by the Program Manager on 10/17/24. A copy of the training sheet has been included as supporting documentation. |
12/20/2024
| Implemented |
| 6400.51(a)(3) | Staff person #11 was hired on 6/10/24 and first worked alone with individuals on 7/7/24. This staff person did not complete the training areas described in 6400.51b1 through 6400.51b5 until 10/2/24. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Staff #11 completed training required in regulations 51b1 through 51b5 on 10/2/24. See Relias transcript. |
12/20/2024
| Implemented |
| 6400.52(c)(1) | Staff person #1 did not complete training in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships in training year July 1, 2023 through June 30, 2024. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Vice President of IDD Services made staff #1 aware of the need to complete training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. These training sessions were completed on 10/24/24 and 10/31/24. See Relias transcript. |
12/20/2024
| Implemented |
| 6400.52(c)(3) | Staff person #1 did not complete training in individual rights in training year July 1, 2023 through June 30, 2024. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Vice President of IDD services made staff # 1 aware of the need to complete training in the area of individual rights on an annual basis. This training will be complete by 12/20/24. |
12/20/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive the following medications:
· 11/8/23 -- 4pm Propranolol
· 11/25/23 -- 4pm Propranolol
· 3/6/24 -- 4pm Propranolol and 8pm Aripiprazole | Medication errors include the following: Failure to administer a medication. | No medications were missed at the times listed as 167(a)(1). Individual #1 was not in the program at the times of listed missed administration. Please see supporting documentation that show Individual #1 was away on leave during that time period. Supporting documentation titled Leave document #1 and Leave document #2 |
12/20/2024
| Implemented |