| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Kindle Charcoal Lighter Fluid and Premium acrylic caulk which indicated to contact poison control if ingested was found unlocked in a cabinet located in the kitchen island.
Family Dollar clear hand soap which indicated to contact poison control if ingested was found unlocked in the bathroom.
| Poisonous materials shall be kept locked or made inaccessible to individuals. | On 2/4/16 the Manager of Residential Services conducted retraining with Program Specialists and Residential Managers to ensure that all poisonous materials are kept locked and inaccessible to individual. The Residential Manager will ensure that all poisonous materials are kept locked.(Residential Staff will conduct daily site checks to ensure poisonous substances are locked. The daily site checks for each house will be documented in the daily log DS 08.03.16) |
02/04/2016
| Implemented |
| 6400.67(a) | The shower stall pipe was exposed from the wall in the shower. | Floors, walls, ceilings and other surfaces shall be in good repair. | The shower pipe was fixed on 2/11/16.
On 2/18/16 the Manager of Residential Services conducted retraining with Program Specialists and Residential Managers on ensuring that all floors, walls, ceilings and other surfaces are in good state of repair.
The program specialists will conduct weekly site visits and will record in their reports any repairs that need to be done. If repairs are needed, a maintenance request will be sent to the Facilities Manager. The Facilities Manager will monitor completion of work orders through weekly inspection report. |
02/18/2016
| Implemented |
| 6400.141(c)(10) | Individual # 1's annual physical examination dated 12/16/2015 did not document if the individual was free of communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Manager of Residential Services will conduct retraining of Program Specialists on ensuring that all individuals¿ physical examinations are completed properly by the physician including: full signature of the physician, date, and all areas of the form are completed. The Health Services manager will conduct the same training with nursing staff. The Program Specialists will review the completed physical examination forms for all of the individuals on their caseload for accuracy. 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 |
| 6400.141(c)(13) | Individual # 1's annual physical examination dated 12/16/2015 did not document if the individual had allergies | The physical examination shall include: Allergies or contraindicated medications. | The Manager of Residential Services will conduct retraining of Program Specialists on ensuring that all individuals¿ physical examinations are completed properly by the physician including: full signature of the physician, date, and all areas of the form are completed. The Health Services manager will conduct the same training with nursing staff. The Program Specialists will review the completed physical examination forms for all of the individuals on their caseload for accuracy. 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 |
| 6400.181(e)(13)(i) | Individual # 1's annual assessment dated 10/03/2015 did not document progress and growth in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| 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)(ii) | Individual # 1's annual assessment dated 10/03/2015 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. | 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 # 1's annual assessment dated 10/03/2015 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 # 1's annual assessment dated 10/03/2015 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 # 1's annual assessment dated 10/03/2015 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 |
| 6400.186(c)(2) | Individual # 1's three month ISP review documentation covering the period of 08/27/2015-11/27/2015 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 |