| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.43(b) |
The family living specialist was not made aware of her responsibilities. The follow monthly summaries for individual # 1 were not signed or dated.
1/27/12, 2/29/12, 3/21/12. 4/30/12,. 5/30/12, 6/30/12. 7/31/1,. 8/31/12, 9/28/12, 10/31/12, and 11/30/12.
| A family living specialist shall be assigned to no more than 8 homes. | The Family Program Director trained all FL Specialist on their job responsibilities as on 12/8/2012. |
12/08/2013
| Implemented |
| 6500.62(a) | A can of Lysol Disinfectant Spray with a label that states "call poison control immediately if swallowed " was left unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Divine Providence implemented a new Home Visit Monitoring Tool for the FL Specialist effective 1/2/13 to be used during weekly phone calls and monthly home monitoring visits. Provider also purchased lock boxes for each home where individuals cannot safely avoid poisonous materials.
Durning the last home visit all poisonous materials were locked. There will be continuous monitoring |
01/02/2013
| Implemented |
| 6500.68(b) | The hot water temerture in the bathroom shower was 134 degrees. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The water temperature was lowered and the FLP was trained on regulations 6500.68 (b) on 12/5/2012. The water temperature was rechecked on 12/10, 12/17, 12/27 and 1/2/13 and remained under 120 degrees.
Effective 1/2/13. Provider implemented a new Home Visit Monitoring Tool for the FL Specialist to be used during weekly phone calls and monthly home monitoring visits. This checklist includes weekly and monthly water temperature checks and documentation of the temperature. If at anytime the water timpertaure exceeds 120 degrees, this will be corrected immediately.
|
01/02/2013
| Implemented |
| 6500.80(c) | There was no soap in the bathroom. | At least one bathroom area shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | During the inpection, on 12/5/2012, The FLP replaced the soap in the bathroom with non toxic hand soap Effective 1/2/13. In addition, Divine Providence has implemented a new Home Visit Monitoring Tool for the FL Specialist to be used during weekly phone calls and monthly home monitoring visits. This checklist includes weekly and monthly checks to ensure that non toxic soap is placed in the bathroom at all times.
|
12/05/2013
| Implemented |
| 6500.156(c)(1) | Individual #1 monthly ISP review for 2/29/12 through 11/30/12, does not list progress on this individual¿s traffic awareness outcome, nor was a revision recommended . | (c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the family living home licensed under this chapter. | On 12/8/2012 the FL Program Director trained all FL Specialist on their job responsibilities associate with the ISP and documentation of outcomes. The most recent montly reflexes progress on each outcome. The Program Director does sample review of monthlies and 3month ISP reviews each month. If there areas of concern the Program Director will offer support and retrain the FLS when necessary. |
12/08/2013
| Implemented |
| 6500.158(c) | The family living specialist did not develop a protocol to implement and track progress on the traffic safety protocol listed in individual #1¿s ISP. dated 7/1/12. | The family living home shall provide services to the individual as specified in the individual's ISP. | On 12/8/2012 the FL Program Director trained the FL Specialist on their job responsibilities associate with the ISP and documentation of outcomes. See attached |
12/08/2013
| Implemented |
| 6500.182(c)(2) | Individual #1 had an incident on 9/17/12 relating to a car accident. The incident report was not included in the individual's record. | ( c) Each individual's record must include the following information: (2) Unusual incident reports relating to the individual. | Provider has filed all unusual incident reports in each individual¿s program book.
Effective 1/2/13 FL Manger will ensure that reports are printed from HCSIS and filed in the appropriate individual records.
|
01/02/2013
| Implemented |