| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | A light switch in Individual # 1's bedroom was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light switch in the bedroom was repaired on 2/4/16.
The Manager of Residential Services will conduct retraining with Program Specialists and Residential Managers on ensuring that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
The Program Specialists will conduct weekly site visits and will record in their reports any lights that are not working and will immediately notify the Facilities Manager via a maintenance request. The Residential Managers will notify Facilities Manager via maintenance request as soon as it is noticed that lights are not working. The Facilities Manager will ensure that non working light switches are repaired. |
07/21/2016
| Implemented |
| 6400.101 | The second floor hallway exit door was unable to open due to the accumulation of ice on the outside | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 2/8/16 the Program Specialist conducted retraining with Residential Managers and group home staff to ensure that all means of egress are continuous and unobstructed to ensure easy accessed in the case of emergency. If it snows, staff on shift will ensure that all egress/exits are clear of snow and ice. The program specialists will be notified by staff if there are any problems with the removal of snow/ice. |
02/08/2016
| Implemented |
| 6400.142(a) | Individual # 2's most recent dental examination was dated 05/19/2015 and there was no documentation of a dental examination in 2014. | 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 Manager of Residential Services will conduct retraining of Program Specialist regarding tracking of annual medical appointments for all individuals on their caseloads. The Health Services manager will conduct the same training with nursing staff. On a monthly basis the program specialists will coordinate with the nurses assigned to the individuals on their caseloads to monitor completion of all annual medical appointments. The Program Specialists will submit a tracking report to the Manager of Residential Services quarterly for review and follow up as needed. Training for Programs Specialists will be completed by 7/21/16. Training for nursing staff will be completed by 8/1/16. |
08/01/2016
| Implemented |
| 6400.142(e) | Individual # 2's dental examination dated 05/19/2015 documented follow up treatment in six months and this did not occur. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The nurse assigned to each individual will ensure that all follow up appointments are scheduled and completed as recommended by the medical personnel. The Manager of Residential Services will conduct retraining of Program Specialist regarding tracking of follow up medical appointments for all individuals on their caseloads. On a monthly basis the program specialists will coordinate with the nurses assigned to the individuals on their caseloads to monitor completion of all annual medical appointments. The Program Specialists will submit a tracking report to the Manager of Residential Services quarterly for review and follow up as needed. Training will be completed on 7/21/16. |
07/21/2016
| Implemented |
| 6400.162(a) | The prescription label on the Ketoconazole shampoo found in individual # 2's medication box was worn and difficult to read | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | The Manager of Residential Services will retrain the Program Specialists and the Residential Managers to ensure that when checking medications, the original container for prescription medications are labeled with pharmaceutical labels that are legible and include the individual¿s name, the name of the medication, the date the medication was issued, the prescribed dose and the name of the prescribing physician. The Residential Managers will review prescription medications three times a week, and document and submit weekly checklists to the Program Specialists for review. The program specialist will review and cross check once a month. Training will be completed on 7/21/16. |
07/21/2016
| Implemented |
| 6400.164(a) | Individual # 2's medication administration record did not document Ketoconazole shampoo which was found in their medication box. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | On 2/18/16 the Manager of Residential Services conducted retraining with Residential Managers and Program Specialists focusing on medication log review. The Residential Managers, in their weekly review of the medication log, will ensure that the medication logs include all prescription medications given, with dosage, time, date and the name for person who administered the prescription medication (both oral and topical) for each individual who do not self-administer. The Residential Managers will document and submit their weekly report to the Program Specialist. The Program Specialists will review and cross check the medication listings of all individuals on their caseloads monthly. |
02/18/2016
| Implemented |
| 6400.181(e)(13)(ii) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. (The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) | On 2/4/16 the Manager of Residential Services conducted retraining with Program Specialists. The focus of the retraining was to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
02/04/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of personal adjustment | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | On 2/4/16 the Manager of Residential Services conducted retraining with Program Specialists. The focus of the retraining was to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
02/04/2016
| Implemented |
| 6400.181(e)(13)(v) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of socialization | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | On 2/4/16 the Manager of Residential Services conducted retraining with Program Specialists. The focus of the retraining was to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
02/04/2016
| Implemented |
| 6400.181(e)(13)(vi) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Manager of Residential Services will conduct retraining with Program Specialists. The focus of the retraining is to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion. Training will be completed on 7/21/16.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
07/21/2016
| Implemented |
| 6400.181(e)(13)(vii) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Manager of Residential Services will conduct retraining with Program Specialists. The focus of the retraining is to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion. Training will be completed on 7/21/16.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
07/21/2016
| Implemented |
| 6400.181(e)(13)(viii) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of managing personal property | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Manager of Residential Services will conduct retraining with Program Specialists. The focus of the retraining is to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion. Training will be completed on 7/21/16.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
07/21/2016
| Implemented |
| 6400.181(e)(13)(ix) | Individual # 2's annual assessment dated 03/20/2015 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Manager of Residential Services will conduct retraining with Program Specialists. The focus of the retraining is to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion. Training will be completed on 7/21/16. (The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
07/21/2016
| Implemented |
| 6400.186(c)(2) | Individual # 2's three month ISP review documentation covering the period of 08/08/2015-11/07/2015 did not review medical appointments. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The Manager of Residential Services will conduct retraining with the Program Specialists focusing on quarterly review requirements, to ensure that all sections of the ISP are reviewed. The Manager of Residential Services will review the quarterly reviews on a regular basis and will check to ensure that medical appointments for the periods of review are included in the quarterly reviews.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) |
07/21/2016
| Implemented |