| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | At the time of this inspection, self-assessments have not been completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| 1. The coordinator and the assistant director were offered retraining on the self-inspection tool as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The directorship (Director and Assistant Director) of the program will utilize an Outlook Calendar in order to prompt them to begin the self-inspection process within the 3-6 months prior to the expiration date. The directorship will be responsible for assisting the house managers in completing the inspections.
3. Future audits of all homes self-inspection tools will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
4. Supporting documentation of retraining will be emailed. |
03/03/2018
| Implemented |
| 6400.141(c)(7) | Breast exams for Individual #6 have not been completed. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 1. The supervisor was offered retraining on the annual physical requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. A breast exam appointment occurred on 6/8/2017 and the results were faxed on 3/1/2018.
3. The home¿s supervisor will closely monitor all future medical appointments to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for breast exams and gynecological documentation.
4. Future audits of all consumers medical records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.141(c)(11) | Health maintenance needs was not completed on Individual #6's physical exam dated 2/16/17. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 1. The supervisor was offered retraining on the annual physical requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals was completed on the consumers physical by 2/27/2018.
3. The home¿s supervisor will closely monitor all future medical appointments to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for completed annual physical documentation.
4. Future audits of all consumers medical records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.141(c)(12) | This section was not completed on Individual #6's physical exam dated 2/16/17. | The physical examination shall include: Physical limitations of the individual. | 1. The supervisor was offered retraining on the annual physical requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The individual¿s annual physical examination section which included physical limitations was completed on the consumers physical by 2/27/2018.
3. The home¿s supervisor will closely monitor all future medical appointments to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for completed annual physical documentation.
4. Future audits of all consumers medical records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.141(c)(15) | This section was not completed on Individual #6's physical exam dated 2/16/17. | The physical examination shall include:Special instructions for the individual's diet. | 1. The supervisor was offered retraining on the annual physical requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The individual¿s annual physical examination section which included special dietary instructions was completed on the consumers physical by 2/27/2018.
3. The home¿s supervisor will closely monitor all future medical appointments to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for completed annual physical documentation.
4. Future audits of all consumers medical records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.167(a) | Staff #6, Staff #21 and staff #22 do not have med practicums; staff #20 and staff #23 do not have initial med trainings for 2017. All 5 staff have been administering medications. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. | 1. The supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The home's staff were trained on the Medication Administration Course on 1/3/2018 and 1/9/2018. Practicums will be completed yearly and tracked through a program spreadsheet.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification.
4. The home¿s supervisor will closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer.
5. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
6. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.168(a) | Staff #20 was hired on 2/24/17 and staff #23 was hired on 8/10/17. Neither had initial med training & have been administering medications. | 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. | 1. The staff and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. All staff were trained in the Medication Administration Course on 1/3/2018 or 1/9/2018 .
3. The home¿s supervisor and directorship will work together to closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer prior to administering medications.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.168(c) | Staff #5 and staff #6's trainer certifications both expired 3/4/2017. Because of this, staff #6 and staff #21 do not have valid practicums. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | 1. The staff and supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The certified trainer who completed the Department¿s Medication Administration Course for Certified Trainers was completed by 12/13/2017.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification. Training expiration dates will be maintained through a program spreadsheet and monitored routinely.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.168(d) | Staff #22 does not have a med practicum and has been administering medications. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. The supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The home's staff were retrained on the Medication Administration course on 1/3/2018 and 1/9/2018. All practicums will be completed on a yearly basis.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.168(e) | Documentation of staff #6, staff #20, staff #22 and staff #23's initial med trainings were not kept. Documentation of staff #22's med practicum was not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 1. The supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. All documentation of the dates and locations of medications administration training for trainers and staff, along with copies of the annual practicum, will be kept in a master file at the office along with the home.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication trainings and practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed the training and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/03/2018
| Implemented |
| 6400.181(e)(13)(viii) | This area was not evaluated on Individual #6's assessment dated 6/15/17. | 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. | 1. The coordinator and the directorship were offered retraining on the individual¿s Outcomes requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The house manager, or those staff who are responsible for attending the ISP meeting, will ensure that all categories reflect and comment on the individual's ability to manage their personal property as well as their progress in this area throughout the year.
4. Future audits of all individual assessments will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. Supporting documentation of corrections and retraining will be emailed. |
03/03/2018
| Implemented |
| 6400.181(f) | Individual #6's ISP meeting was held on 7/12/17. Her assessment wasn't provided to her team until 6/19/17. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| 1. The coordinator and the directorship were offered retraining on the annual assessment requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/3/2018.
2. The house manager, coordinator and all other staff who are responsible for completing the annual assessment, will ensure that all future annual assessments are submitted to the Supports Coordinator 30 calendar days prior to the ISP meeting and are compliant and documented accordingly.
3. The directorship will assist the coordinators with completing the 30-Day ISP checklist prior to it being submitted to the supports coordinator.
4. Future audits of all individual records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. Supporting documentation of corrections and retraining will be emailed. |
03/03/2018
| Implemented |