| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | The canteen closet was unlocked and contained poisonous materials. Poisonous materials included Lysol cleaner, A1 Bleach, and Drano. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.
Violation: The canteen closet was unlocked and contained poisonous materials. Poisonous materials included Lysol cleaner, A1 Bleach, and Drano.
Plan of Correction: On 2/21/2020 the Operations Manager conducted training with all staff regarding the requirement that all poisonous materials must remain locked and inaccessible to Individuals when not in use. Documentation of training will be maintained in staff records.
Operations Manager or designee will conduct weekly walk through inspections to ensure compliance with the regulation. Issues noted will be corrected immediately. Documentation of weekly inspections will be kept.
Correction date: 2/21/2020 |
| Implemented |
| 2380.58(a) | There is a nickel size hole in the wall in the kitchen area where a telephone used to hang. | Floors, walls, ceilings and other surfaces shall be in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair.
Violation: There is a nickel size hole in the wall in the kitchen area where a telephone used to hang.
Plan of Correction: On 3/18/2020 the hole was patched/repaired.
On 2/21/2020 the Operations Manager conducted training with all staff regarding this regulation. Documentation of training will be maintained in staff records.
Operations Manager or designee will conduct weekly walk through inspections to ensure that the physical site is in good repair. Issue will be noted and repair requests submitted through the Track-It system. Documentation of weekly inspections and Track-It submissions will be kept.
Correction date: 3/18/2020 |
| Implemented |
| 2380.111(c)(9) | The physical form dated 1/21/2020 for individual #5 did not contain information related to her allergies or contraindicated medications. It was left blank. Also, the individual's most recent ISP dated 1/07/2020 does indicate that the individual has several allergies including seasonal, yeast, dogs/cats, grass, and cockroaches. | The physical examination shall include: Allergies or contraindicated medication. | The physical examination shall include: Allergies or contraindicated medication.
Violation: The physical form dated 1/21/2020 for individual #5 did not contain information related to her allergies or contraindicated medications. It was left blank. Also, the individual's most recent ISP dated 1/07/2020 does indicate that the individual has several allergies including seasonal, yeast, dogs/cats, grass, and cockroaches.
Plan of Correction: On 2/21/2020 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement.
On 4/6/2020 an ISP change form was submitted to the Supports Coordinator requesting that the ISP language be changed to reflect that the allergies were diagnosed by an ENT specialist rather than the PCP. Provider has confirmed that a copy of the ENT report is present in the consumer's program book.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer's physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.111(c)(11) | Most recent physical dated 1/21/2020 for individual #5 did not contain information on special diet instructions; it was left blank. Also, the individual should not have yeast in her diet according to the individual's most recent ISP dated 1/07/2020 due to an allergy. | The physical examination shall include: Special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual's diet.
Violation: Most recent physical dated 1/21/2020 for individual #5 did not contain information on special diet instructions; it was left blank. Also, the individual should not have yeast in her diet according to the individual's most recent ISP dated 1/07/2020 due to an allergy.
Plan of Correction: On 2/21/2020 training was conducted by the Operations Manager for Program Specialists regarding this regulatory requirement.
On 4/6/2020 an ISP change form was submitted to the Supports Coordinator requesting that the ISP language be changed to reflect that the yeast allergy was diagnosed by an ENT specialist rather than the PCP. Provider has confirmed that a copy of the ENT report is present in the consumer's program book.
The Manager, Corporate Compliance, or their designee will conduct a 100% review of consumer physicals to determine compliance. If issues are noted, the Program Manager will be contacted to correct the issue.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer's physicals to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.171(b)(1) | Phone number was not included for individual #5's emergency contact. | Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
Violation: Phone number was not included for individual #5's emergency contact.
Plan of Correction: On 2/17/2020 the Program Specialist added the phone number for emergency contact to Individual #5's face sheet.
On 2/21/2020 the Operations Manager conducted training with Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.171(b)(2) | The name, address, and phone number of individual #'5's physician was not easily accessible in individual #5's record according to regulation 171a. | Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care. | Emergency information for each individual shall include: The name, address and telephone number of the individual's physician or source of health care.
Violation: The name, address, and phone number of individual #'5's physician was not easily accessible in individual #5's record according to regulation 171a.
Plan of Correction: On 2/17/2020 the Program Specialist added the name, address and phone number of PCP to Individual #5's face sheet.
On 2/21/2020 the Operations Manager conducted training with Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.171(b)(3) | Individual #4 face sheet does not identify the person(s) able to give medical consent. Individual #1's face sheet does not identify the person(s) able to give medical consent. Individual #2 face sheet does not identify the person(s) able to give medical consent. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
Violation: Individual #4 face sheet does not identify the person(s) able to give medical consent. Individual #1's face sheet does not identify the person(s) able to give medical consent. Individual #2 face sheet does not identify the person(s) able to give medical consent.
Plan of Correction: On 2/17/2020 the Program Specialist added person able to give medical consent to Individual #4's face sheet.
On 2/21/2020 the Operations Manager conducted training with Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.173(1)(ii) | Individual #4's face sheet does not include identifying marks. The space was left blank. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.
Violation: Individual #4's face sheet does not include identifying marks. The space was left blank.
Plan of Correction: On 2/17/2020 the Program Specialist added identifying marks to Individual #4's face sheet.
On 2/21/2020 the Operations Manager conducted training with Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.173(1)(iv) | Individual #4's face sheet does not include Religious Affiliation. The space was left blank. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Each individual's record must include the following information: Personal information including: Religious affiliation.
Violation: Individual #4's face sheet does not include Religious Affiliation. The space was left blank.
Plan of Correction: On 2/17/2020 the Program Specialist added Religious affiliation to Individual #4's face sheet.
On 2/21/2020 the Operations Manager conducted training with Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.176(a) | A tall 4 drawer filing cabinet near the shredding area was unlocked which contained tablets with individual's first names and last initials and their non-current daily work tallies. | Individual records shall be kept locked when they are unattended. | Individual records shall be kept locked when they are unattended.
Violation: A tall 4 drawer filing cabinet near the shredding area was unlocked which contained tablets with individual's first names and last initials and their non-current daily work tallies.
Plan of Correction: On 2/13/2020 the Operations Manager installed a lock on the file cabinet. On 2/21/2020 the Operations Manager conducted training with all staff regarding this regulation. Documentation of training will be maintained in staff records.
Operations Manager or designee will check during routine weekly walk through inspections to ensure the cabinet is locked. Documentation of weekly inspections will be kept.
Correction date: 2/21/2020 |
| Implemented |
| 2380.181(e)(4) | The supervision section individual #3's 1/10/2020 Assessment is unclear. During the day it states he can be in another room safely without direct supervision for up to 5 hours. Also, if necessary, individual #3 can be in the day program building alone for up to 1hr. Individual #3 can be on the day program's property outside without direct supervision and staff will check on him every 15 minutes. The Assessment also states he always has someone with him in the community. These statements regarding his service needs and supervision do not support what is in his current Individual Plan 12/26/2019. | The assessment must include the following information: The individual¿s need for supervision. | The assessment must include the following information: The individual's need for supervision.
Violation: The supervision section individual #3's 1/10/2020 Assessment is unclear. During the day it states he can be in another room safely without direct supervision for up to 5 hours. Also, if necessary, individual #3 can be in the day program building alone for up to 1hr. Individual #3 can be on the day program's property outside without direct supervision and staff will check on him every 15 minutes. The Assessment also states he always has someone with him in the community. These statements regarding his service needs and supervision do not support what is in his current Individual Plan 12/26/2019.
Plan of Correction: On 2/10/2020 and 3/27/2020 the Program Specialist contacted Individual #3's Supports Coordinator to update the ISP to reflect the correct information regarding his supervision needs. On 3/12/2020 an addendum to assessment was completed.
On 2/21/2020 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.181(e)(9) | The most recent assessment dated 10/30/19 did not contain information regarding individual #5's Disability, and functional and medical limits. Individual #4's assessment dated 04/04/19 does not include documentation of her disability. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.
Violation: Individual #1's 12/20/19 assessment does not include documentation of his disability.
Plan of Correction: On 3/27/2020 the Program Specialist updated #1's assessment to include documentation of his disability.
On 2/21/2020 the Operations Manager conducted training with the Program Specialists regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 1, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of staff training files to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.36(a) | Content of the providers staff fire safety training does not include notification to the local fire department as soon as possible after a fire is discovered. | 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 facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | 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 facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.
Violation: Content of the providers staff fire safety training does not include notification to the local fire department as soon as possible after a fire is discovered.
Plan of Correction: On 2/21/2020 the Operations Manager conducted training with al staff, including employee #2, regarding how to notify the local fire department as soon as possible after a fire is discovered. Documentation of training will be maintained in staff records.
On 2/20/20 the orientation outline was revised to include specific language about notification of the local fire department as soon as possible after a fire is discovered.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of staff training files to ensure compliance with regulations. Documentation of quarterly reviews will be kept.
Correction date: 4/15/2020 |
| Implemented |
| 2380.185(1) | Supervision in individual #3's current Individual Plan 12/26/2019 only states he needs assistance to cross the streets. There is supervision at all times monitoring the area where he works. These statements do not give a clear, complete accurate representation of individual #3's abilities and service needs. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.
Violation: Supervision in individual #3's current Individual Plan 12/26/2019 only states he needs assistance to cross the streets. There is supervision at all times monitoring the area where he works. These statements do not give a clear, complete accurate representation of individual #3's abilities and service needs.
Plan of Correction: On 2/18/2020 and 3/27/2020 the Program Specialist contacted Individual #3's Supports Coordinator to update the ISP to reflect the correct information regarding his supervision needs. On 3/12/2020 an addendum to assessment was completed.
On 2/21/2020 training was conducted by the Operations Manager for Program Specialist staff regarding this regulatory requirement. Documentation of training will be maintained in staff records.
Beginning April 15, 2020 and continuing for a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of consumer assessments to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
| Implemented |