| 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 ledger for the savings account jumped up by 10 cents with no explanation. The ledger was never corrected. The ledger for August 2020 for Individual #1's personal account had an ending balance of 176.89. The next month, the beginning balance was documented as 176.87. Individual #1's October 2020 ledger for the personal account had an ending balance of 39.47. The beginning balance for November 2020 was documented as 39.65. | 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 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 # 63 no later than 12/5/2021. |
12/05/2021
| Implemented |
| 6400.22(f) | On 1/9/21, Individual #1 went to McDonald's. The total removed from Individual #1's account was $8.96. The receipt was for $13.51; indicating Staff purchased food as well. A $20 bill was used to pay for the meal. It is unclear, who's money was used to make this purchase. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | Staff will be trained on regulation 6400.22 (f) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 63. |
11/15/2021
| 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 # 65. 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(a) | Individual #1 had a physical examination completed on 3/5/20 and not again until 3/30/21; outside of the annual time frame. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Director of Quality Assurance (MP) will meet with PS (MR) 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 # 66 no later than 8/30/2021. Staff will be trained on regulation 6400.141 (a) 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(e) | Individual #1 requested dentures. Individual #1 was scheduled to have a consult on 3/12/21 that was canceled due to Covid. As of 7/1/21, the appointment has not been rescheduled. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Individual #1 has been scheduled for an appointment on 8/20/21. Please see Attachment # 67. 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 # 66 no later than 8/30/2021. Staff will be trained on regulation 6400.142 (e) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 37. A copy of the exam will be sent as Attachment # 68 once completed. |
08/30/2021
| Implemented |
| 6400.181(a) | Individual #1's assessment was completed 10/30/19 and not again until 11/12/20; outside of the annual time frame. | 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 (MP) will meet with PS to help develop a tracking mechanism for all dates as required for 6400 regulations. A completed tracking chart will be completed and sent as Attachment # 44 no later than 8/30/2021. PS 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 |
| 6400.34(a) | Individual #1's rights were reviewed on 7/9/19 and were not reviewed again until 8/31/20; outside of the annual timeframe. | 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. | Director of Quality Assurance will meet with PS to help her develop a tracking mechanism for all dates as required for 6400 regulations. A completed tracking chart will be completed and sent as Attachment # 44 no later than 8/30/2021. PS will be trained on regulation 6400.34 (a) and it will be sent no later than 8/30/2021, signature sheet will be sent as Attachment # 69. |
11/15/2021
| Implemented |
| 6400.46(a) | Staff #17 had Fire Safety training on 11/8/20. Staff #1's first day working with Individuals was 11/7/20. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the 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. | During COVID certain trainings were provided in the homes and as a result Staff #17s fire safety training wasn't completed until the day after she started working directly with clients. This was an oversight on behalf of the home supervisor who will be trained on regulation 6400.46 (a) no later than 8/30/2021. |
08/30/2021
| Implemented |
| 6400.52(c)(6) | Individual #1 has an updated Gait Belt/Stair Safety Protocol dated 10/7/20. The following staff were not trained on the protocol: Staff #1 through Staff #24. Individual #1 has a Chewing Tobacco Protocol dated 10/4/19. The following staff were not trained on this protocol: Staff #2, Staff #13, Staff #16, Staff #17, Staff #23, Staff #25, and Staff #26. Individual #1 has a Soda Protocol dated 10/4/19. The following staff were not trained: Staff #2, Staff #9, Staff #13, Staff #16 through Staff #18, Staff #23, Staff #25-through Staff #30. Individual #1 has a constipation protocol dated 10/4/19. The following staff were not trained: Staff #2, Staff #13, Staff #16 through Staff #18, Staff #21 through Staff #22, and Staff #25 through Staff #30. | 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. | Some staff are no longer with the agency the others will be trained on Individual #1 POS no later than 8/30/2021. Signatures of the trainings will be sent as Attachment # 72. Home supervisors & PS will receive training for regulation 6500.52 (c) (6) no later than 8/30/2021, signature sheet will be sent as Attachment # 58. |
08/30/2021
| Implemented |
| 6400.165(b) | Individual #1 began taking Gauifenesen in February 2021, Pepto-Bismol in March 2021, and Ventolin in April 2021. No documentation was provided that these medications were prescribed. | A prescription order shall be kept current. | There are no orders from any of Individual #1s PCP or other doctors for Pepto-Bismol and Gauifenesen. Both of these medications have been pulled and disposed of. A medication disposal form was completed and is being sent as Attachment # 73. An order was obtained for the Ventolin and is being sent as Attachment # 74. Home Supervisors and PS will be trained on regulation 6400.165 (b) no later than 8/30/2021 and will be sent as Attachment # 75. |
12/30/2021
| Implemented |
| 6400.165(c) | On 8/4/21, staff held Individual #1's Polyethylene Glycol without a doctor's recommendations to do so. There is no documentation that Individual #1's Famotidine was administered from 4/22/21 to 4/30/21. There is no discontinue order for this medication. | A prescription medication shall be administered as prescribed. | IM reports were filed on EIM for medication errors, IM# 8887174 and IM#8887211. Home Supervisors and PS will be trained on regulation 6400.165 (c) no later than 8/30/2021 and will be sent as Attachment # 75. |
02/15/2022
| Implemented |
| 6400.166(a)(1) | Individual #1 has no medication records for December 2020. | 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 |
| 6400.166(a)(7) | Individual #1's Vimpat increased to 150mg in September 2020. The change was not reflected on the MAR until January 2021. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | When MARs are completed each month, they are to be verified by a home supervisor that the MARs match the pharmacy labels. Home supervisors will be trained on regulation 6400.166 (a) (7) no later than 8/30/2021 and will be sent as Attachment # A. |
02/15/2022
| Implemented |
| 6400.166(a)(12) | In April 2021, Staff duplicated 4/22/21 on Individual #1's MAR making it unclear as to the actual dates of medication administration from 4/22/21 to the end of the month. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | IM Report was filed on EIM, IM # 8887174. Staff will be trained on regulation 6400.166 (a) (12) no later than 8/30/2021 and will be sent as Attachment # 80. When MARs are completed each month, they are to be verified by a home supervisor that the MARs match the pharmacy labels. Home supervisors will be trained on regulation 6400.166 (a) (12) no later than 8/30/2021 and will be sent as Attachment # A. |
02/15/2022
| Implemented |
| 6400.166(a)(13) | Staff not initialing when meds are given for the following dates for Individual #1: 1/2/21, 1/4/21 to 1/6/21, 1/8/21, 1/13/21, 1/15/21, 1/17/21, 1/18/21, 1/24/21, 1/25/21, 2/1/21-2/4/21, 2/6/21-2/10/21, 2/12/21-2/17/21, 2/19/21-2/20/21, 3/3/21, 3/15/21, 4/3/21, 4/5/21-4/10/21, 4/21/21-4/23/21, 5/2/21-5/4/21, 5/13/21-5/14/21. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | When MARs are completed each month, they are to be verified by a home supervisor that the MARs match the pharmacy labels. All Staff passing medication at 972 E Water Street for will be trained on regulation 6400.166 (a) (13) no later than 8/30/2021 and will be sent as Attachment # 81. Home supervisors will be trained on regulation 6400.166 (a) (13) no later than 8/30/2021 and will be sent as Attachment # A. |
02/15/2022
| Implemented |
| 6400.181(f) | Individual #1's team meeting was held on 10/15/20. Individual #1's assessment was not provided to the team and SC until 11/12/20. | 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 her develop a tracking mechanism for all dates as required for 6400 regulations. A completed tracking chart will be completed and sent as Attachment # 44 no later than 8/30/2021. Staff 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. |
08/30/2021
| Implemented |
| 6400.195(a) | Individual #1 has tobacco intake restricted per a doctor's recommendations. This restriction is not part of Individual #1's restrictive plan. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | PS has been in contact with PCPs office to obtain a current order for tobacco usage recommendations. Once obtained a copy will be sent as Attachment # 82. A new order is needed for the Behavior Specialist to write the restriction into his BSP. |
08/30/2021
| Implemented |