| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was to be completed between October 2020 and February 2021. No self-assessments were completed during that time frame. | 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.
| A process was developed to show that all self-assessments of the residential group homes are to be completed between the months of October of the previous year and February of the current year in order to maintain compliance. Please see Attachment # 1. All responsible parties (Program Specialist/home supervisors/verifiers) will be trained on this process no later than 8/30/2021. A copy of the training sheet will be sent as Attachment # 2 once completed. All parties will be trained on regulation 6400.15 (a) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 3. |
08/30/2021
| Implemented |
| 6400.22(e)(1) | Individual #1's September 2020 Personal Ledger had an ending balance of 7.45 after the ledger was reconciled. The beginning balance for October 2020, was $8 (the amount before the ledger was reconciled). The March 2021 Personal ledger for Individual #1 has a transaction amount of 71.45 on 3/26/21. The receipt is only for $71.39. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | A procedure was developed to address the requirements and responsibilities for house account ledgers. A copy of the procedure is being sent as Attachment # 24. Residential oversight designee, home supervisors and PS will be trained on the new procedure no later than 8/30/2021. A copy of the training sheet signed by will be sent as Attachment # 25. Residential staff will be trained on the procedure and sent no later than 10/30/2021 as attachment # 26. Home supervisors and PS will be trained on regulation 6400.22 (e) (1) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 27. A copy of Individual # 1's November Ledger will be reviewed by home supervisor to ensure all receipts are accounted for and balance is accurate as well. Copies of the Novembers house account ledger along with required receipts will be sent as Attachment # 28 no later than 12/5/2021. |
12/05/2021
| Implemented |
| 6400.112(e) | A sleep drill was held on 10/17/20 and not again since. | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight sleep drill was attempted at Water Street on 7/31/2021 and again on 8/5/2021, both drills were not successful due to refusals from one of the clients.He has not been feeling well and was diagnosed with a sinus infection which could be playing a factor into the refusals due to lack of sleep and aggression he has been showing. Continued attempts will occur for an overnight fire drill in August until successful or a plan of support will be implemented following guidance from the RCG for this regulation. This will be sent as Attachment # 30. Home supervisors will be trained on regulation 6400.112 (e) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 19. |
08/30/2021
| Implemented |
| 6400.113(c) | The annual fire safety training curriculum does not include identifying the designated meeting place. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Fire Safety Emergency Evacuation procedure was developed as an attachment to the Individual Fire Safety Training Content. This procedure contains basic information for staff and individuals in regards to evacuations procedures and clearly states where the meetings places are located for each residential home. This procedure will be reviewed with each individual and no later than 8/30/2021 and a copy of their signed procedure will be obtained and sent as Attachment # 31. Home supervisors and PS will be trained on regulation 6400.113 (c) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 8. |
08/30/2021
| Implemented |
| 6400.141(c)(6) | Individual #1 had a TB test on 8/19/18 and not again until 11/23/20, outside of the bi-annual time frame. | 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. | Director of Quality Assurance will meet with PS to help her develop a tracking mechanism for all medical appointments to ensure that individuals are receiving necessary appointments, immunizations, and screening done within their required time frames. A completed tracking chart will be completed and sent as Attachment # 32 no later than 8/30/2021. Home supervisors and PS will be trained on regulation 6400.141 (c) (6) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.141(c)(9) | Individual #1 did not have a prostate exam completed. No deferment letter was in the record. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual #1 deferment letter dated 7/31/2021 was obtained. Please see Attachment # 34. Home supervisors and PS will be trained on regulation 6400.141 (c) (9) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.141(c)(11) | Individual #1's most recent annual physical completed 11/19/20 had the health maintenance needs section blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Received new annual physical on 7/30/2021 where the individuals health maintenance needs, medication regimen and the needs for blood work at recommended interval was completed by the physician. Please see Attachment # 35. Home supervisors and PS will be trained on regulation 6400.141 (c) (11) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.141(c)(12) | Individual #1's most recent annual physical dated 11/19/20 did not have the physical limitations section listed on it at all. | The physical examination shall include: Physical limitations of the individual. | received new annual physical on 7/30/2021 where the physical limitations of the individual was reviewed by the physician. Please see Attachment # 35. Home supervisors and PS will be trained on regulation 6400.141 (c) (12) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent annual physical completed 11/19/20 had the section addressing information pertinent to treat/diagnose in the event of an emergency blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Received new annual physical on 7/30/2021 where the medical information pertinent to diagnosis and treatment in case of an emergency was reviewed by the physician. Please see Attachment # 35. Home supervisors and PS will be trained on regulation 6400.141 (c) (14) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.141(c)(15) | Individual #1's most recent annual physical completed 11/19/20 had the section addressing special diet blank. | The physical examination shall include:Special instructions for the individual's diet. | Received new annual physical on 7/30/2021 where special instructions for the individuals diet was reviewed by the physician. Please see Attachment # 35. Home supervisors and PS will be trained on regulation 6400.141 (c) (15) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 33. |
08/30/2021
| Implemented |
| 6400.142(a) | Individual #1 was to have a dental exam on 11/23/20. It was canceled due to Covid. As of 7/1/21, the appointment has not been rescheduled. | 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. | PS emailed Individual #1s dentist to schedule an appointment, it is in the process of getting scheduled in late October. Reason for the longer time frame is due to the fact that needs sedation for all dentistry and his travel cannot be too far from his home due to his medical issues and care needs. Please see Attachment # 36. Director of Quality Assurance will meet with PS to help her develop a tracking mechanism for all medical appointments to ensure that individuals are receiving necessary appointments, immunizations, and screening done within their required time frames. A completed tracking chart will be completed and sent as Attachment # 32 no later than 8/30/2021. Home supervisors and PS will be trained on regulation 6400.142 (a) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 37. |
08/30/2021
| Implemented |
| 6400.144 | Individual #1 has a bowel movement protocol that if Individual #1 has no bowel movement in 3 days, milk of magnesia is to be administered. If Individual #1 has no bowel movement in 4 days, a suppository must be administered. If Individual #1 has no bowel movement in 5 days, Individual #1's PCP is to be called. Individual #1 had no bowel movement documented from 11/23/20 to 11/27/20. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 12/22/20 to 12/24/20. No milk of magnesia was given. No bowel movement was documented from 1/3/21 to 1/6/21. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 1/8/21 to 1/10/21. No milk of magnesia was given. No bowel movement was documented from 1/21/21 to 1/23/21. No milk of magnesia was given. No bowel movement was documented from 1/27/21 to 1/30/21. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 2/1/21 to 2/5/21. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 2/16/21 to 2/19/21. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 2/27/21 to 3/1/21. No milk of magnesia was given. No bowel movement was documented from 3/15/21 to 3/19/21. No milk of magnesia was given. No suppository was administered. No bowel movement was documented from 4/1/21 to 4/7/21. No milk of magnesia was given. No suppository was administered. Primary Care Physician was not called. No bowel movement was documented from 4/28/21 to 4/30/21. No milk of magnesia was given. Individual #1 is to be checked on every two hours. Individual #1 was not checked on every two hours on 11/2/20 and from 5/27/21 to 5/29/21. | 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.
| Individual # 1 did not have a BM tracking sheet to cover all shifts and required checks. Individual #1's 2 hours checks clearly showed a section for tracking whether Individual #1 had a BM during those time frames. However, Individual #1's overnight paperwork (30 minute checks) did not have a space for tracking whether they had a BM or not so it is unclear if had a BM during overnight shifts and that is why his MAR shows that he wasnt receiving the MOM or suppositories. Home supervisors and PS will be trained on regulation 6400.144 and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 38. All staff need to be retrained of Plan of Support for constipation. This will be completed by 8/30/2021 and sent as Attachment # 39. Individual #1 was not in our care 5/27/2021 thru 5/29/2021 due to hospitalization for his hernia surgery, the following documentation: Attendance Record is being sent as Attachment #40 to verify this. Documentation is missing from 2:30pm-8:00pm for Individual #1's 2 hours checks. It is unclear if the checks were completed and not signed off on or if they even occurred. |
09/15/2021
| Implemented |
| 6400.181(a) | Individual #1's date of admission was 9/1/2020. Individual #1's initial assessment was not completed until 3/6/21. | 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. | Director of Quality Assurance will meet with the Program Specialist to help them develop a tracking mechanism for all dates as required for 6400 regulations. A tracking chart will be completed and sent as Attachment # 44 no later than 8/30/2021. Program Specialists will be trained on regulation 6400.181 (a) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 45. |
11/15/2021
| Implemented |
| 6400.211(b)(2) | Physician's contact information is not included in Individual #1's record content. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Updated face sheet to include the name, address and telephone number of the individual's physician for individual #1. A copy of the face sheet is being sent in as Attachment # 46. Program Specialist will receive training for regulation 6500.211 (b) (2) no later than 8/30/2021, signature sheet will be sent as Attachment # 47. |
11/15/2021
| Implemented |
| 6400.32(r) | Individual #1 was not offered the option to have a lock on Individual #1's bedroom door. | An individual has the right to lock the individual's bedroom door. | Information has been added to ISP. Please see attachment # 53. |
11/15/2021
| Implemented |
| 6400.52(c)(6) | Individual #1 has a seizure protocol dated 9/1/20. Staff #1 has not received this training. Individual #1 has an NPO protocol, a monthly weight protocol, a Gerd protocol, a dental hygiene protocol, a Bi-pap protocol, and a G-tube protocol all dated 9/1/20. Staff #2 has not received any of these trainings. Individual #1 has a Constipation/BM protocol and a Range of Motion Protocol dated 9/1/20. Staff #3, Staff #4, and Staff #5 did not have these trainings. Staff were to receive the following trainings for Individual #1 after hospitalizations and ER visits: 9/16/20-EIM states staff were to be trained on what to look for regarding issues with g-tube. On 9/25/20 the EIM states staff were to be trained on what to look for when suspecting aspiration and pneumonia. And on, 11/21/20, EIM states staff were to be trained on what to do and what to look for if bleeding from ostomy site would occur again. No documentation was provided that any staff received these three trainings. | 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. | Staff #1, #2, #, #4 & #5 will be trained on Individual #1 POS no later than 8/30/21. Signatures of the trainings will be sent as Attachment # 56. Staff will be provided with training in regards to all follow up information from Individual #1s ER visits on 9/25/2020 and 11/21/2020 no later than 9/30/2021. Copies of training records will be sent as attachment # 57. Residential oversight designee, home supervisor and PS will receive training for regulation 6500.52 (c) (6) no later than 8/30/2021, signature sheet will be sent as Attachment # 58. |
09/30/2021
| Implemented |
| 6400.162(a) | Individual #1 receives medications via a G-Tube. Staff administering the medications to Individual #1 via the G-Tube have not been trained by a medical professional. | 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. | Individual #1s PCP provided guidance as to the type of preferred medical professional that could train staff. Please see documentation to this affect as attachment # 50. An LPN will be obtained to train all staff that work directly with Individual #1 and will be providing medication to the individual via their G-Tube. Once all staff are trained, the signature sheet from the training will be sent as Attachment # 51. Residential oversight designee, home supervisors and program specialists, will receive training for regulation 6500.162 (a) no later than 8/30/2021, signature sheet will be sent as Attachment # 52. |
08/30/2021
| Implemented |
| 6400.165(c) | Individual #1's is prescribed milk of magnesia and a suppository when Individual #1 goes three and four days consecutively with no bowel movement. The milk of magnesia and suppository are not being administered as prescribed. | A prescription medication shall be administered as prescribed. | Individual # 1 did not have a BM tracking sheet to cover all shifts and required checks. Individual #1's 2 hour checks clearly showed a section for tracking whether the individual had a BM during those time frames. However, the overnight paperwork (30 minute checks) did not have a space for tracking whether the individual had a BM or not so it is unclear if the individual had a BM during overnight shifts and that is why the MAR shows that the individual wasn't receiving the MOM or suppositories. Home supervisors and Program Specialists will be trained on regulation 6400.165 (c) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 61. All staff need to be retrained on Individual #1's Plan of Support for constipation. This will be completed by 8/30/2021 and sent as Attachment # 39. |
09/15/2021
| Implemented |
| 6400.166(a)(1) | No documentation was provided verifying Individual #1 had medication records from 9/2020 to 12/2020, or from 2/2021. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | At this time MARs for individual #1 have not been able to be obtained. Home supervisors will be trained on Regulation 6400.166 (a) (1) and will be sent as Attachment # A no later than 8/30/2021. |
11/15/2021
| Implemented |
| 6400.181(f) | Individual #1's assessment was sent to the team on 3/6/21. The team meeting for ISP was held on 3/10/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Director of Quality Assurance will meet with PS to help them develop a tracking mechanism for all dates as required for 6400 regulations. A tracking chart will be completed and sent as Attachment # 44 no later than 8/30/2021. Program Specialist will be trained on regulation 6400.181 (f) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 45. |
11/15/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's record does not identify next of kin. | Each individual's record must include the following information: Next of Kin | Updated face sheet to include next of kin. A copy of his face sheet is being sent in as Attachment # 46. PS will receive training for regulation 6500.213 (1) (v) no later than 8/30/2021, signature sheet will be sent as Attachment # 60. |
11/15/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's Religious Affiliation section is blank in the record. If Individual #1 has no religious affiliation, please indicate so. | Each individual's record must include the following information: Religious Affiiliation | Updated face sheet to include religious affiliation. A copy of his face sheet is being sent in as Attachment # 46. PS will receive training for regulation 6500.213 (1) (iv) no later than 8/30/2021, signature sheet will be sent as Attachment # 60. |
11/15/2021
| Implemented |