| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(c) | An incident occurred involving Individual #4 on 11-25-14 and it was not reported until 1-5-15. | The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| Staff who performed the inappropriate restraint resigned his position before we were aware of what happened. When we were notified of the restraint in December we notified the county and were instructed to include the restraint in another HCSIS report completed on the psychiatric hospitalization. We were later notified by the county that we needed to do a separate and an investigation. We initiated an investigation at that time. All remaining staff were retrained on the Agency policies on the use of restraints, Positive intervention techniques and Incident management procedures including timely reporting of incidents on 12/29/14 and on the individuals behavior plan on 1/6/15. See attached training sheet. The Incident Manager will monitor to ensure that all staff receive the necessary training and will follow up with appropriate disciplinary procedures if protocol is not followed. |
01/06/2015
| Implemented |
| 6400.18(d) | An incident occurred involving Individual #4 on 11-25-14 and it was not investigated until 1-5-15. | The home shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department to the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 72 hours after an unusual incident occurs.
| Staff who performed the inappropriate restraint resigned his position before we were aware of what happened. When we were notified of the restraint in December we notified the county and were instructed to include the restraint in another HCSIS report completed on the psychiatric hospitalization. We were later notified by the county that we needed to do a separate and an investigation. We initiated an investigation at that time. All remaining staff were retrained on the Agency policies on the use of restraints, Positive intervention techniques and Incident management procedures including timely reporting of incidents on 12/29/14 and on the individuals behavior plan on 1/6/15. See attached training sheet. The Incident Manager will monitor to ensure that all staff receive the necessary training and will follow up with appropriate disciplinary procedures if protocol is not followed. |
01/06/2015
| Implemented |
| 6400.64(a) | Individual #1's bedroom carpet had dark stains that were approximately 3 inches in diameter. The 1st floor shower room had mold on the wall. There were stains under the kitchen sink that were consistent with mold. | Clean and sanitary conditions shall be maintained in the home. | All staff, supervisors, maintenance personnel and management personnel have been retrained on ensuring that all areas of the home are in good repair and on timely reporting of any issues to the appropriate staff. See attached training sheets. Residential Managers will complete an outlined inspection of their sites on a monthly basis and submit checklist to their supervisor. Maintenance personnel will also complete an outlined inspection of their assigned sites monthly and submit the checklist to their supervisor. Please see attached checklists. Third Shift Supervisor has a revised nightly checklist to ensure all areas are checked thoroughly. Administrative staff conduct site inspections twice per month. See attached reports. The carpet was removed on 12/7/14. Mildew in shower and under kitchen sink was taken care of on 9/29/14 and then cabinets, sink and plumbing were replaced on 1/7/15.See attached work orders. |
01/07/2015
| Implemented |
| 6400.168(a) | Staff A who was hired on 9/12/11, administered medication during the month of September, yet has not completed the Department of Public Welfare's Medication Administration Training, | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | The medication trainer was retrained by the Human Resources Manager on 9/30/14 to ensure that documentation of staff medication testing, trainings and observations are correctly and properly written on all forms and to ensure that staff names and dates are clearly written and accurate on all forms as the paperwork was missing the staff identifiers on some pages. See attached training sheet. The trainer will monitor all recall dates to ensure all staff are in compliance. The Human Resources Manager will monitor quarterly. |
09/30/2014
| Implemented |
| 6400.186(a) | Individual #4 ISP was dated 1/30/14; the most recent ISP review was dated 4/30/14. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The Program Specialists were trained on 9/24/14 regarding completing an ISP review of the services and expected outcomes in the ISP every 3 months or more frequently if the individuals needs change. See attached training sheet. The Manager of Residential Services will monitor through a tracking system to ensure that quarterlies are completed as required. |
09/24/2014
| Implemented |
| 6400.186(c)(3) | Individual #4¿S ISP date 1/30/14 identifies residential supports, behavioral supports, social and recreation activities, as well as health and safety as needed outcomes. The monthly summaries from January 2014 through August 2014; does not indicate that progress has been made. However, there is no documentation to indicated that the program specialist made recommendation for modifications to the outcomes. | The ISP review must include the following: The program specialist shall document a change in the individual's needs, if applicable. | The Program Specialists were retrained on 9/24/14 regarding ensuring that all outcomes remain appropriate for the individual and ensuring that if no progress is being made that they initiate making changes to the individuals plan. The Program Specialists will monitor through review of Monthly progress notes and will document any need for changes to outcomes in their quarterly reviews and in an email to the supports coordinator. The Manager of Residential Services will monitor through review of monthly and quarterly notes. |
09/24/2014
| Implemented |
| 6400.194(a) | A restrictive procedure was utilized involing Individual #4 on 11-25-14 and there was not an approved restrictive plan as part of the record. | If a restrictive procedure is used, there shall be a restrictive procedure review committee.
| Staff who performed the inappropriate restraint resigned his position before we were aware of what happened. When we were notified of the restraint in December we notified the county and were instructed to include the restraint in another HCSIS report completed on the psychiatric hospitalization. We were later notified by the county that we needed to do a separate and an investigation. We initiated an investigation at that time. All remaining staff were retrained on the Agency policies on the use of restraints, Positive intervention techniques and Incident management procedures including timely reporting of incidents on 12/29/14 and on the individuals behavior plan on 1/6/15. See attached training sheet. The Incident Manager will monitor to ensure that all staff receive the necessary training and will follow up with appropriate disciplinary procedures if protocol is not followed. |
01/06/2015
| Implemented |