Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242367 Renewal 04/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the 04/24/24 inspection, there were cracks in the wall to the left of the front door and on the ceiling near the light fixture in the dining area. There were chair rail marks to the right of the front door and on the walls around the dining table.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance request was submitted on 05/07/2024 to fix the cracks in the Ceiling, walls and chair rail marks in the dining room. 06/30/2024 Implemented
SIN-00225472 Renewal 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, the vent in Individuals #1's and #2's bathroom had a layer of dust on the vent screen. There was a thousand legger crawling on the wall in the same bathroom. Individual #1's shower in their bathroom had a dead bug in the shower wrapped around what appeared to be a ball of hair.Clean and sanitary conditions shall be maintained in the home. The vent was cleaned of dust as well as the dead bug wrapped around a ball of hair on 06/16/2023. A maintenance request was submitted to Briar Crest Apartments on 07/19/2023. (See email attachment) (Attachment of Vent) (Attachment of Bathroom Tub) 08/20/2023 Implemented
6400.66The exterior egress light by the front door was not operable during the 6/15/23 inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The exterior egress light by the front door was repaired by Briar Crest Apartment Maintenance team on 06/16/2023. (see picture of light) 08/20/2023 Implemented
6400.67(a)At the time of the inspection, Individuals #1's and #2's bathroom had rust spots covering the bottom of the inside of the bathtub and rust on the outside of the bathtub. The floor in the same bathroom was peeling by the tub. The caulk was peeling and bubbling away from the tub and the wall. There was rust and black spots over all these areas. The combination bathtub/shower in the same bathroom did not have a shower drain stopper. When testing the water temperature in the shower, the bathtub filled up quickly, and did not drain fast enough to keep up with the flow of water. The entire living room wall had a crack in the drywall located on the wall behind the couch. The cover plate to the shower head in Individual #1's shower was not affixed to the wall to protect and cover the water pipe.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance request was submitted on 07/19/2023 (see email of maintenance request) to repair rust in and out of the bathroom tub, peeling in the bathroom, black spots, caulk, drainage flow, crack in living room drywall behind couch, and the cover plate to protect and cover the water pipe. The repairs will be completed by 8/20/23. 08/20/2023 Implemented
6400.72(b)At the time of the inspection, the sliding screen door had two rips in the screen material by the handle. One rip was slightly larger than the other, with the larger hole being approximately 1.5 inches in diameter. Screens, windows and doors shall be in good repair. A maintenance request was submitted on 07/19/2023. (see email of maintenance request) to fix the sliding door screen and will be repaired by 8/20/23. 08/20/2023 Implemented
6400.77(b)At the time of the inspection, the first aid kit in the home didn't contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The thermometer in the First Aid kit was replaced during the inspection on 06/16/2023. (picture attached 1st aid kit and thermometer). 08/20/2023 Implemented
6400.111(f)The home was unable to produce the date the fire extinguishers were inspected and approved in 2022. The home produced an invoice that was created on 5/7/2022 stating payment is required for the inspection of fire extinguishers, indicating the inspection happened sometime prior to 5/7/2022. The home did not have the fire extinguishers inspected and approved again until 5/23/23, more than 365 days after an inspection prior to 5/7/2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The agency scheduled next year's appointments for all sites for the fire extinguisher inspections. The appointment is scheduled for May 13, 2024 at 8:00 am. The company will also give a courtesy call 30 days prior as a reminder or if a rescheduled date will be needed. (Email attachment) 08/20/2023 Implemented
6400.144Part 2: continued from 1st 6400.144 violation description According to the physician's print out from 2/6/23, Individual #1 was provided instructions to frequently use an incentive spirometer to prevent atelectasis and pneumonia- at least 10 times per hour while awake, seek immediate medical care if develop difficulty breathing, new or severe pain, worsening couch, generalized weakness, pallor, or fever, use Tylenol per box instructions for pain, lidocaine patch per box instructions for pain, get plenty of rest, and limit weight restriction- no more than 5lbs and limit activity until fully healed. Individual #1 continued to experience new and worsening pain from 2/6/23-2/19/23. The home failed to seek immediate medical care due to the pain and swelling witnessed and reported by Individual #1 spanning 13 days after a fall and after instructed to seek immediate medical care for worsening conditions on 2/6/23. The following was documented in the individual's record: · 2/6/23 didn't complete compression pumps or wear stocking · 2/7/23 didn't wear stockings · 2/9/23 bruise on the top and right upper side of right foot · 2/10/23 bruise on right top of foot, declined exercised on due to left foot hurting, and still has a bruise on top of right foot top and reported to staff they hit their foot on the 4th, before 3pm · 2/11/23 feet were too swollen to put on stockings, they could hardly walk on their feet, a big black and blue bruise witness on the individual's left foot, staff put ice and kept the individual's feet elevated during shift, and still had a bruise · 2/12/23 foot is sore and swollen, right foot has a bruise, big black and blue on left foot, a nice amount of swelling in both feet, staff iced them and kept them elevated, with no indication if stockings worn · 2/13/23 didn't complete exercises as foot is still in pain, didn't wear stocking on right foot because hurting and bruised, right foot is black and blue · 2/14/23 Individual #1 declined stocking and stated their foot hurt too much to wear them, had black and blue mark on their right foot from when they fell, didn't complete compression pumps, didn't complete exercises reporting their foot hurt, and had to walk around the home and outside the home due to their motorized wheelchair not working, still has bruise on foot · 2/15/23 had to walk today because their motorized wheelchair wasn't working, declined stocking today due to swelling in foot and pain, still has a bruise · 2/16/23 right foot still bruised, still not wearing stocking · 2/17/23 right foot bruised and reported in pain, and decline stocking on right foot, still very swollen · 2/18/23 bruise on right foot, didn't wear stocking · 2/19/23 home didn't monitor or document daily concerns. · Pain medications were only administered as follows: acetaminophen 650mg at 4pm on 2/7/23 and 7:45am on 2/9/23, ibuprofen 400mg at 12:15pm on 2/6/23, 7:45pm on 2/6/23, and 6:30pm on 2/10/23. After instructions on 2/6/23 for further treatment to complete at home, an incentive spirometer was never purchased and used by the individual, lidocaine patches were never applied or offered, and Tylenol was never administered, but acetaminophen and ibuprofen were. Individual #1 saw their physical medicine and rehabilitation specialist on 3/9/23. The physician's record states to see the formal note for detail. During the 6/13/23 inspection, the home did not have the physician's note for the details provided at this appointment, nor did they have access to any portal that would hold this information. Per the agency, Community Interactions, during the inspection they reported Individual #1 is to be completing physical therapy exercises. The individual's 4/20/23 assessment stated that the individual's mobility is decreasing, and physical therapy has been ordered. The home was unable to produce the physical therapy orders from 3/9/23, or records of the physical therapy orders the individual was to be completing over the previous year. Individual #1 saw their physical medicine and rehabilitation specialist on 3/21/23 and was to return in 6-8 weeks. At the time of the 6/13/23 inspection, Individual #1 is not scheduled to return until 6/15/23. The home did not have record if 6/15/23 was the earliest appointment or if the appointment was late getting scheduled. The 3/21/23 appointment record had a return date of 6/15/23 added to the appointment record, but the record did not document who or when this return date was added to the appointment summary. On 3/21/23 Individual #1's physician indicated the individual is to have an MRI on their right ankle and foot, use volt gel three times a day on their right ankle, ice their right ankle three times a day, and to elevate their right ankle. Individual did not have an MRI of their right foot and ankle until 4/4/23. The 4/4/23 physician's note stated that the results of the MRI will follow with the ordering physician. At the time of the 6/13/23 inspection, the home did not know the results of the 4/4/23 MRI, the individual's record did not have record of the results, and the home did not contact the ordering physician to determine if they received the results or had an explanation of further recommendations from the MRI. During the 6/13/23 inspection the agency reached out for MRI results and obtained them on 6/15/23. There isn't documentation the individual elevated their leg, iced their leg, or purchased and used volt gel for pain as ordered. On 3/13/23 the individual's occupational therapist ordered the individual to use compression pumps daily at night for both legs and should wear compression stocking daily during the day, range of motion exercises 3x/week, encourage to walk throughout day, and Velcro compression wraps on both legs. On 5/18/23 their occupational therapist included specific instructions about some durable medical equipment ordered. They were: the wraps that attach to shoe laces should only be worn when Individual #1 needs to walk and can be applied over Velcro wraps, do not put Individual #1's regular socks on overtop wraps, the individual should wear Velcro wraps during the day for 8 hours, not at night, remove Velcro wraps at night, if left on longer than 8 hours staff are to check skin to make sure there are no red marks, ask Individual #1 if they have pain, straps can be adjusted if they voice they are too tight or if staff noticed red marks. The home failed to produce records that all physician's orders were being implemented to maintain the individual's leg and foot health. The home was not monitoring or tracking if the individual had any red marks on their skin. Individual #1 requires staff assistance to recognize, report, and assist the individual when they are sick and require medical intervention. The following worsening health condition was documented by staff in the individual's record, and the home did not seek medical attention timely: · 4/23/23 they didn't wear their compression stockings and had a heating pad on their ankle for 20 mins · 4/26/23 wasn't feeling well, didn't do compression pumps or wear stockings, and had a stuffy nose · 4/27/23 stayed home sick, didn't do exercises, compression pump or wear stoking due to not feeling well, went to bed at 8pm stating they aren't feeling well. · 4/28/23 staff offered medications to help with cold symptoms and the individual declined. They are not feeling well. · 4/29/23 resting due to their sinuses and not feeling well · 4/30/23 stayed home sick and wasn't feeling well The home didn't take Individual #1 to be seen by a medical professional until 5/1/23, for the congestion and sinus pain. The agency nurse printed off an appointment form on 4/28/23 in preparation for the 5/1/23 appointment, indicating management staff was aware Individual #1 was not feeling well days prior to being assisted to be seen by their physician. continued on next 6400.144 violation descriptionHealth services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A GRE-Body Check Tool was implemented in Therap. DSP's will complete this daily. In addition, the Nurse/Designee/PS will review the GRE's daily. If an injury/swelling/bruising is identified the individual's primary care physician will be notified immediately if needed and no later than 48 hours after the start of the symptoms, if warranted by the Agency Nurse/Designee. 08/20/2023 Implemented
6400.144Part 3: continued from 2nd 6400.144 violation description During the 6/15/23 home inspection the Velcro wraps were at the home and Individual #1 was out in the community with staff. Per agency staff on 6/16/23, Individual #1 only has one pair of Velcro wraps so they were not wearing them in the community 6/15/23 as ordered and there's no record if they refused to wear them or if they were offered. There is daily documentation if Individual #1 is wearing stocking but no records for wraps were also worn. On 8/1/22 Individual #1's neurologist ordered laboratory blood work to be completed every 6 months, CBC and CMP. At the time of the 6/15/23 inspection, this has not been completed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All follow up appointments and correspondence with prescribing physicians, all trainings will be scheduled and completed by the Agency Nurse or Designee to ensure compliance is maintained in this area by 09/30/2023. 08/20/2023 Implemented
6400.144Part 1: Individual #1 saw their dentist on 9/9/2022 and was to return in 6 months. Their return appointment scheduled on 3/10/2023 did not occur due to staff arriving late to the dental appointment. The dental office had to reschedule the appointment to 3/30/2023 since the home was late bringing Individual #1 to the appointment. On 3/20/23 Individual #1's dentist recommends getting an occlusal guard to use due to the patient having severe wear throughout dentition. There are no records that the home has purchased this for the individual, or if the individual uses the device as ordered and recommended, or if the individual refuses to use the device. Individual #1 is ordered an as needed medication for constipation. The home is not tracking or monitoring the individual's bowel movements to know if, and when, the medication needs administered. Individual #1 has quarterly visits ordered to be completed with their primary care physician. Individual #1 did not have a few quarterly appointments as scheduled, with their primary care physician. The home documented that the following appointments were rescheduled but doesn't indicate who rescheduled the appointments or why they weren't completed as scheduled: 9/22/22 appointment did not occur until 10/5/23. During the 6/15/23 inspection it was reported to the Department that the agency staff did not take Individual #1 to their appointment on the correct date. The primary care physician had scheduled the appointment for 9/21/22, however the home had recorded the incorrect date and didn't take the individual to their physician until 9/22/22. Individual #1 is diagnosed with venous insufficiency, hypertension, athlete's foot, lymphedema, scoliosis, cerebral palsy, and pain in ankle and joints. Individual #1 is to have the following adaptive medical equipment available to use daily: wheelchair, walker, sturdy sneakers with dorsiflexion straps, compression socks, compression pump, therapy exercises, compression wraps, and gait belt per their individual support plan (isp). The home reports the individual is to use the compression socks daily on both feet/legs. The home was unable to produce the current medical orders for use of sturdy sneakers with dorsiflexion straps, or the orders for compression socks and compression pump from July 2022 to March 2023. Individual #1 had a podiatrist appointment scheduled for 1/25/23. This appointment was not completed and a note in the individual's record stated it was rescheduled. However, the note doesn't indicate why it was rescheduled. The individual had their podiatrist appointment on 1/26/23. The agency did not have knowledge of why the 1/25/23 appointment was missed. Staff documented Individual #1 did not wear their compression socks on 1/2/23, 1/3/23, 1/4/23, and 1/7/23. Staff noted Individual #1 had a bruise on their left shin on 1/5/23. On 1/10/23 staff documented Individual #1 only wore their compression sock on their right foot because the individual's left foot is very tender, and ankle is bothering them. Staff continued to document the individual is having pain and swelling in their left foot on 1/11/23 and did not wear their compression socks on their left foot this day. On 1/12/23 staff continued to document that the individual's left foot was swollen, the individual didn't wear their compression sock on that foot and was taken to their primary care physician for the swelling and pain. There are no records that the home attempted to contact medical professional prior to 1/12/23 when they noticed the swelling and pain in the individual's foot days prior to, and with a diagnosis and history of lymphedema and pain and swelling in the feet. On 1/12/23 the individual's physician saw the individual for swollen and painful left foot. They recommended the individual get an x-ray of their left foot, an ultrasound of left leg veins, continue Tylenol 500mg by mouth every 4-6 hours, continue using compression socks, and elevate their leg. Staff document they administered 650mg of acetaminophen once a day on 1/10/23, 1/12/23, and 1/13/23, but never Tylenol or the dose ordered by the physician. There are no records the home had the individual elevate their leg. There are no records of the results of the x-ray that staff reported the individual received on 1/12/23. Individual #1's daily notes indicate the individual is to use their compression pump in the evening for 60 minutes. The compression pump at Individual #1's home allowed staff to choose a variety of locations to place the compression pumps and use on Individual #1. According to a sample of daily records, the records do not document if the compression pump was placed on the trunk and lower extremities; records only document "pump" if used. Additionally, there are days when the compression pump was not utilized, and no explanation is recorded for the failure to implement the isp. Examples documented were, no use on 2/3/23 with a reasoning of "not tonight," no use on 2/6/23 "due to back hurting from fall," no use on 1/12/23 "it was too late to complete them," declined on 1/13/23, "n/a" recorded for 1/14/23, not completed on 1/4/23, only completed the compression pump on both legs on 4/1/23 and 4/2/23, and staff applied the individual's compression pumps twice on 4/4/23. On 2/6/23 Individual #1 was seen at med express "due to fall yesterday and having pain in their back." The home did not document when the fall occurred, any specifics regarding the fall, nor did they have the seen immediately after the fall. The home did not contact medical professionals immediately after the fall. Individual #1 had diagnoses that alter their gait and require them to use adaptive equipment to assist with ambulation, thus making them a fall risk. The home does not have any plans in place for fall prevention or have a fall assessment/risk completed for the individual. continued on next 6400.144 violation descriptionHealth services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Therap is equipped with a medical appointment reminder. The nurse or designee is responsible to input the dates of appointments and when they are due. At the 30-day mark and a week prior, the administrative staff get a reminder about the appointment. Once the reminder is received, they communicate the appointment date and time to the DSP's. A tracking tool will be implemented in the THERAP system to capture consistent on going monitoring of the following: Occlusal guards, Compression socks, pumps, adaptive equipment, monitoring bowels, cancellation protocols and documentation, complete a fall assessment/risk assessment. All follow up appointments and correspondence with prescribing physicians, all trainings will be scheduled and completed by the Agency Nurse or Designee to ensure compliance is maintained in this area by 09/30/2023. 08/20/2023 Implemented
6400.181(e)(12)Individual #1's current, 4/20/23 assessment doesn't include recommendations for specific areas of training, programming and services. The assessment states, "none at this time."The assessment must include the following information: Recommendations for specific areas of training, programming and services. The assessment for individual #1 was documented and revised (see assessment changes on document Apr. 2023) to reflect the recommendations for specific areas of training, programming and services. 08/20/2023 Implemented
6400.32(v)Individual #1's bed is equipped with bedrails that restrict the individual's movement in and out of bed. The home is unable to provide medical documentation that a physician has ordered the bed rails. The home does not have documentation that the danger of the bedrails were explained to Individual #1 nor that they signed off agreeing they want to continue using the bedrails. The home does not have a plan in place for the individual to be safely checked on and how often they will be checked on while using the bedrails.An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.Documentation will be received from the doctor verifying Individual #1's need for bedrails. In addition, by 8/8/23, a document will be reviewed with Individual #1 reviewing the dangers of the bedrails and the individual's agreement they want to continue using bedrails. A safety plan was implemented for individual #1. The safety plan will include 30-minute checks, while in the bed. This will be documented using our agency's electronic healthcare tracking record. 08/20/2023 Implemented
6400.34(a)REPEAT from 7/5/22 annual inspection: Individual #1 had their rights reviewed with them on 1/1/22 and again on 1/1/23. However, the review of individuals' rights reviewed with Individual #1 on 1/1/22 did not include a review of all rights defined in 6400.31-33. The home indicated in their plan of correction from their 7/5/2022 annual inspection, that all individuals' rights will be updated and completed, and all homes will be reviewed to ensure compliance with this regulation by 9/30/22. At the time of the 6/14/23 inspection, Individual #1 did not have all their rights, defined in 6400.31-33, reviewed with them until 1/1/23; over 3 months after the agency reported this would be fixed.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Clients Rights Packet (Individual Rights) has been updated per the current year to reflect a review of all rights defined in 6400.31-33 (Attachment) 08/20/2023 Implemented
6400.51(b)(5)Individual #1 has multiple health diagnosis that require the use of durable medical equipment and adaptive devices. There was no training provided that all staff working with the individual were trained in how to use and operate the devices. The following durable medical equipment and adaptive devices are prescribed to Individual #1 for daily use: compression stocking, compression wraps, compression pumps, special utensil to eat, gait belt (per their agency, Community Interactions Inc. assessment), wheelchair, walker with large wheels, requires assistance with all transfers, shower chair, raised toilet seat, has physical and occupational therapy exercises to perform daily, orders not to put the compression stocking over the compression wraps, and specific orders for the time of day and how long to use the compression items, and sturdy sneakers with dorsiflexion straps. Individual #1 has a communication device and communication goals and outcomes. Training records were never produced to show all staff working with the individual were trained on the individual's communication needs and abilities, outcomes, and devices. The individual has a seizure action plan. Training records to show staff received training on this plan were never produced.The orientation must encompass the following areas: Job-related knowledge and skills.All training will be scheduled and completed by the Communication Specialist, Agency Nurse, or Designee to ensure compliance is maintained in this area by 08/20/2023. 08/20/2023 Implemented
6400.163(b)Individual #1's carbamazepine medication packet was dispensed from the pharmacy in a 30-day supply pack where each pill was individually packaged in single pill pockets. During the 6/15/23 onsite inspection, a carbamazepine pill was popped out of an individual pocket, then a pill was re-taped back into the individual pocket, and a pill was then re-popped back out through the tape of the individual pill pocket. The medication was removed from it's original container in advance of administration.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.The medication was damaged while being mailed for delivery from a remote pharmacy. Moving forward, any damaged medications resulting in a damaged blister pack will be immediately returned within 24 hours and re-blistered to ensure that it remains in its original container. If the blistered medication cannot be returned within a decent amount of time, a local pharmacy will be contacted and a script will be written and sent to a local pharmacy and will be filled to ensure compliance with medication regimen. 08/20/2023 Implemented
6400.166(b)REPEAT from 7/5/2022 annual inspection: Staff documented they administered acetaminophen to Individual #1 at 4:30pm on 1/12/23 but did not record this administration until 9:03pm on 1/12/23. Staff documented they administered acetaminophen to the individual at 4pm on 2/7/23. Staff signature represents administration of the medication. However, staff signed the individual's medication administration record (mar) at 3:52pm on 2/7/23, prior to administration of the medication.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Based on the information provided, The Direct Support Professional failed to adhere to the medication protocol in following the 5 rights- Written timely documentation as it pertains to the PRN. This employee will attend performance concern will be documented in writing with the employee. The Direct Support Professional that made the medication documentation error will attend one task force committee meeting, receive Medication Administration Refresher training conducted by the Certified Medication Trainer, performance concern will be documented in their personnel file, accordingly. 08/20/2023 Implemented
6400.167(a)(4)Individual #1's June 2023 medication administration records (mars) document most of their 8am and 8pm medications were not administered within one hour prior to or after the scheduled time of administration. During the 6/15/23 onsite inspection, carbamazepine, cetirizine, levetiracetam, metoprolol, enulose, and reguloid powder 8am administrations on June 3rd, 4th, 7th, 10th, 11th, and 13th, were signed as administered on the mar anywhere from 9:39am-12:36pm for the day of administration referenced. The individual's 8pm medications on June 3rd, 6th, 12th, and 13th, were signed as administered between 9:03pm, and not until 7:55am the following day.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.Based on the information provided, The Direct Support Professional failed to adhere to the medication protocol in following the 5 rights- Written timely documentation as it pertains to the PRN. This employee will attend performance concern meeting and will be documented in writing with the employee. 08/20/2023 Implemented
6400.169(a)REPEAT from 7/5/2022 annual inspection: Staff person #1 completed the Department's modified medication administration online course on 3/20/21. However, they did not complete all requirements of the modified medication administration course, in lieu of the standard course, as outlined in the Department's bulletin. There are no records that Staff person #1 was trained in the provider's medication administration record system used for medication administration documentation, nor are there records of a date that a medication trainer reviewed all training requirements and provided a certification date for Staff person #1's 2021 annual training. From 2021 to current, 6/14/23, Staff person #1's 2022 and 2023 annual modified medication administration trainings did not include two of the four medication administration record review requirements, for each year, outlined in the Department's bulletin.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Based on the information provided, Staff person #1 did not complete all requirements of the modified medication administration course, in lieu of the standard course, as outlined in the Department's bulletin. Staff person #1 will attend a new Medication Administration Training completed by a Certified Trainer in order to meet compliance, based off of not having the two of the four medication review requirements. Due to not being able to produce the records, during the transition of websites on Medication Administration Training, Staff person #1 will complete a full course in Medication Administration training conducted by the Certified Medication Trainer 08/20/2023 Implemented
6400.181(f)Individual #1's annual individual support plan meeting was held on 5/3/2023, per the agency's (Community Interactions Inc.) program specialist. The individual's 4/20/2023 assessment was not created until 4/20/2023, thus not able to be sent more than 30 days prior to the individual's 5/3/2023 annual planning meeting. The individual's record states that on 3/14/2023 the individual's assessment was sent to team members. However, the assessment wasn't created until 4/20/2023. There are no records produced to document who, if any, the individual's 4/20/23 assessment was provided to after completion.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Moving forward, the Program Specialist will provide the assessment to the individual plan team members at least 30 calendar days prior to an individual planning meeting. 08/20/2023 Implemented
6400.183(c)Per the agency's (Community Interactions Inc.) program specialist, Individual #1's annual individual support plan planning meeting was held on 5/3/23. A list of those in attendance was not kept by the agency, nor in the individual's record.The list of persons who participated in the individual plan meeting shall be kept.Moving forward , Program Specialist will always maintain their own agency copy of a sign in sheet. 08/20/2023 Implemented
6400.185(4)Individual #1 is working with communication support and using proloquo2go application on their tablet to communicate with staff and those in their life. The individual's assessment doesn't include information about the usage of the proloquo2go they are receiving, what the individual is working on, or how the individual is to use the proloquo2go application to assist with communication. Per their communication specialist, the individual is working on spelling, articulation and using the proloqo2go to communicate with staff. The individual has goals for communication. The specific goals were not included in the individual's individual support plan (isp).The individual plan, including revisions, must include the following: Services to assist the individual to achieve desired outcomes.All scheduled trainings for all DSPS, Lead Staff, and Administrators will be conducted on 07/31/2023 by the Communication Specialist in support of services to assist the individual achieve desired outcomes. The Program Specialist will update the assessment to reflect the changes and contact the Support Coordinator to ensure desired outcomes are updated in the ISP with the current Communication goals and outcomes. The Program Specialist will also include the tracking of the desired goal on a quarterly basis for ongoing monitoring and compliance. 08/20/2023 Implemented
6400.186Individual #1's individual support plan (isp) states the individual is doing range of motion exercises daily and is to drink 64 ounces of water daily. The home did not produce records that this is being monitored, completed, or tracked. Individual #1 receives communication support and the home is to work on communication goals with the individual. Individual #1's communication support plan includes communication goals: to clarify their message using the iPad when they are not understood, make request and comments to others when in the community, and will type of variety of words to main their spelling. According to communication support notes from August 2022 to May 2023, staff are to continue to work with Individual #1 on their communication goals. Individual #1 is to use their iPad and proloquo2go communication application for communication needs. During the 6/15/23 inspection, Individual #1 was out in the community with staff and their communication device was at home, unavailable to use out in the community. Individual #1's isp states they are prescribed trunk and lower extremity compression pump therapy to be completed 1 hour daily in the home. The compression pump at Individual #1's home allowed staff to choose a variety of locations to place the compression pumps and use on Individual #1. According to a sample of daily records, the records do not document if the compression pump was placed on the trunk and lower extremities; records only document "pump" if used. Additionally, there are days when the compression pump was not utilized, and no explanation is recorded for the failure to implement the isp. Examples documented were, no use on 2/3/23 with a reasoning of "not tonight," no use on 2/6/23 "due to back hurting from fall," no use on 1/12/23 "it was too late to complete them," declined on 1/13/23, "n/a" recorded for 1/14/23, not completed on 1/4/23, only completed the compression pump on both legs on 4/1/23 and 4/2/23, and staff applied the individual's compression pumps twice on 4/4/23. Individual #1's current, 4/20/23 assessment states they receive hourly checks during the night. There are no records the home is completed said checks for the individual's safety. Individual #1's current, 4/20/23 assessment and isp do not indicate the individual can handle any amount of money on their person independently, but that they require full staff assistance with money management. During the 6/15/23 inspection, there were records that $45 was given to the Individual #1 on 6/15/23, $40 on 1/24/23, $50 on 2/22/23, $5 on 3/25/23, $50 on 3/29/23, $10 on 3/30/23, $12.66 on 3/30/23, $50 on 4/27/23, and $12 on 5/7/23 to handle independently.The home shall implement the individual plan, including revisions.All training will be scheduled and completed by the Communication Specialist, Agency Nurse or Designee, Team Facilitator or Designee to ensure compliance is maintained in this area by 08/20/23. 08/20/2023 Implemented
SIN-00207438 Renewal 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)At the time of the inspection there was no nonslip surface in the standup shower. Bathtubs and showers shall have a nonslip surface or mat. A new non slip bath mat was placed in the home standup shower. 09/30/2022 Implemented
6400.112(h)From August 2021 through June 2022 there were seven fire drills conducted in which it was not documented whether the individuals met at the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The agency Fire Drill Form will be redrafted to include the necessary updates. All staff will be retrained on the new form by the Program Specialist and Team Facilitator. 09/30/2022 Implemented
SIN-00194014 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The "future call" picture phone did not have the emergency numbers posted on or near the device.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. 1. The future call picture phone was replaced with the emergency numbers posted near the device on 09/20/2021 (see attachment # 1 future phone call picture). 01/31/2022 Implemented
6400.77(b)The first aid kit did not contain tweezers at the time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 1. The tweezers in the First Aid kit were replaced on 09/18/21. 01/31/2022 Implemented
6400.112(h)There are no records maintained that all individuals evacuated to the meeting place during every monthly fire drill held from September 2020 to current, August 2021. According to the fire drill records, the meeting place is documented on the records as the lamp post. There is no indication on the records if individuals evacuated to the meeting place during every monthly drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.1. The fire drill form was revised to reflect that all individuals evacuated to the meeting place during monthly fire drill. (Attachment# 5 revised fire drill form) 01/31/2022 Implemented
SIN-00176452 Renewal 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of inspection, there was a golf ball sized amount of lint in the dryer's lint trap. Floors, walls, ceilings and other surfaces shall be free of hazards.1. The lint trap in dryer was cleaned on the spot on 09/10/2020 (see attachment #1). 2. Direct Support Professionals (DSP) will be re-trained on removing lint after every load. 3. The training will be completed by the Team Facilitator or designee. 4. On a daily basis, the DSP¿s will check and document using the Daily Overnight checklist to ensure compliance with CI¿s guidelines as pertaining to lint. (Attachment #2) 5. On a weekly basis, the House Manager, Lead Staff, Cluster Administrator, or designee will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with environmental checks. (Attachment #3) 6. The Monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster (Attachment #4). 7. House Manager/Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance. This training will be completed by the Associate Residential Director. 8. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.112(c)The fire drill record was not accurate regarding date and time of the fire drills. The fire drill held on 1/23/20 at 2am indicated it was Friday and sunny. 1/23/20 was actually a Thursday. It is unclear as the actual date and time of the drill. 6/16/20 a fire drill was held. The log stated it was a Wednesday. 6/16/20 was actually a Tuesday. It is unclear as the actual date of the drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. 1. DSPs will be retrained on the importance of paying attention to details when completing the fire drill report, to be accurate on the date, day of the week, time of the day, as well as weather conditions 2. After a fire drill is completed the Lead Staff/House Manager/Team Facilitator will be review the reports for accuracy, before being submitted to the Program Specialist (attachment #5 ) 3. The Program Specialist will also review the reports before filing 4. The Program Specialist will conduct quarterly reviews and document on the fire drill review checklist (attachment #6) 5. DSPs, Lead Staff, House Manager, and Cluster Administrators will be trained by Associate Residential Director 6. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.34(a)The Department issued updated rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 9/9/20 annual inspection, individual #1 was never informed of the individual rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.1. The Client¿s Rights Packet was revised to include the Regulatory Compliance Guidelines (RCG), including the individual¿s right to lock their bedroom door (attachment#7) 2. The Program Specialists will inform all the individuals of their rights and review the newly revised Client¿s Rights Packet to meet the regulatory requirements. Thereafter, and on an annual basis or as needed the Client¿s Rights Packets will be reviewed with the individuals and signed. 3. All DSP¿s and Cluster Administrators will be re-trained on new additional rights as per the RCG and Client¿s Rights Packet. 4. The Associate Residential Director will retrain all Cluster Administrators, who will in turn train the DSP¿s. 5. This will be completed by 12/31/2020 12/31/2020 Implemented
SIN-00157430 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Inside the home on the left side of the front door, approximately 4ft up from the floor there in a large black scratch in the wall approximately and inch in width and approximately a foot in length. This is from an individual's electric wheelchair being parked against the wall. Suggested a chair rail. Left side baseboard in the hallway is worn and the paint is chipped off.Floors, walls, ceilings and other surfaces shall be in good repair. 1. The wall was repaired 10/30/2019 (attachment #7) 2. Our Weekly and Monthly PA /QA Audit forms have been revised to include paint- scratches These forms will be completed by the Lead Staff, Team Facilitator and Program Coordinator/Specialist. 3. The Associate Director or designee will be reviewing the Monthly PA QA Audit on a Quarterly basis beginning March 2020. 4. The Residential Director will train everyone on the new forms before 12/31/19. 5. The newly revised forms will become effective in 1/15/20. 01/15/2020 Implemented
SIN-00135382 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)Fire drill records did not indicate whether or not individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A new user friendly fire drill report form was created as well as a new fire drill review form (see attachment #2&3). It was developed in order to ensure all fire drill related regulations are met, including the designated meeting place. All personnel and Program Coordinator will be trained on the approved forms. 09/11/2018 Implemented
6400.113(a)Individual #1 and Individual #2 completed fire safety training on 10/4/2017. No documentation was present in either record to indicate fire safety training was completed annually (no 2016 documentation present). An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. 1. The documentation was filed away during the inspection and was not found in enough time prior to the closing of licensing. (see attachment #9) for the Individual #1 and individual #2. 2. The Program Coordinator and Associate Director have created a filing system that will ensure timeliness upon request of record 09/11/2018 Implemented
6400.144Individual #1 had an annual gynecological exam on 5/17/2017 with a one year recall, and none since. Individual #1 had a vision screening on 10/6/2015 with a one year recall. Next vision screening was completed on 10/17/2017.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual # 1 went to her annual gynecological appointment on 9/05/2018 and she is now in compliance. (see attachment #8a, 8b, 8c) 2 The current tracking system will be re-evaluated and revised by the Healthcare Team (Health & Wellness Administrators, Nurses, and Coordinator) accordingly by 10/31/2018. 10/31/2018 Implemented
6400.145(3)The written emergency medical plan did not list the following: An emergency staffing plan.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A written emergency medical plan was updated to include an emergency staffing plan (attachment #6&7) 09/11/2018 Implemented
6400.181(e)(12)Individual #1's assessment dated 2/15/2018 did not include the following information: Recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. 1. The assessment for individual #1 was updated to include recommendations (see attachment #4 ) 2. A checklist to be used by the Program Coordinator was developed to capture all aspects required in an assessment ¿including the recommendation section (see attachment #5). This checklist and training for all the Program Coordinators will be done by 10/31/18. (see attachment) 10/31/2018 Implemented
6400.213(11)Individual #1's current physical dated 9/6/17 lists no known diagnosed allergies (NKDA). The current assessment dated 2/15/18 lists allergies as seasonal, and bee stings. The current ISP documents that Individual #1 is prescribed medication for allergies, and also states if Individual is stung by a bee, Benadryl should be administered and goes further to state that individual does not have a diagnosis of an allergy to bee stings, but will swell if stung. MAR's indicate medication is prescribed for seasonal allergies. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. 1. Individual # 1 doctor will confirm sensitivity to (bee stings) Venom Protein (honey Bee). All documents will have formal diagnosis ISP, Annual Physical, and (Assessment updated 8/6/18- see attachment #4). Doctor will provide written documentation by 10/31/18. 2. The current tracking system will be re-evaluated and revised by the Healthcare Team (Health & Wellness Administrators, Nurses, and Program Coordinator) accordingly by 10/31/2018. 10/31/2018 Implemented
SIN-00112364 Renewal 05/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)REPEATED VIOLATION- 5/16/16. Staff #1 was hired on 9/6/16. Staff #1 was not trained on daily operations of the home.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. All newly hired staff will receive on-site orientation related to their responsibilities, and policies and procedures/daily operation of the home before working with individuals. 05/05/2017 Implemented
6400.106There was no documentation that the furnace was inspected and cleaned for 2015 and 2016. Each apartment has it's own furnace unit. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Our 6400.106 protocol has been updated and the following procedures have been instituted; ¿ Documentation has been obtained from Briarcrest Gardens as proof of furnace cleanings for 2015 and 2016 for the home. See attachment #6 ¿ Program Coordinator will obtain proof of annual furnace cleanings for the home from Briarcrest Garden¿s property manager. ¿ Person Responsible: Program Specialist. May 30, 2017 To Whom It May Concern: This letter serves as confirmation that the following services have been performed on the HVAC unit at 11 Williamsburg, Hershey, PA, which is part of Briarcrest Gardens Rental Community. This is apartment is currently leased by Community Interactions Group. November 23, 2015-filter was changed October 6, 2016-filter was changed 2017-To be completed in the fall If you have any questions or concerns, please contact our office. Thank you, Melissa Nottke Property Manager MNottke@horstrealty.com 05/30/2017 Implemented
6400.112(a)REPEATED VIOLATION- 5/16/16. A fire drill was not completed in May and June of 2016. An unannounced fire drill shall be held at least once a month. Our 6400.112(a) protocol has been updated and the following procedures have been instituted; ¿ All staff will be re- trained on responsibilities of completing monthly fire drills and the importance of ensuring forms are filled out at the completion of the drill. All completed monthly fire drill forms will be turned into the program coordinator and/or program specialist for review. ¿ Person Responsible: Program Coordinator and/or Program Specialist. 06/30/2017 Implemented
6400.141(c)(1)Individual #1's 1/9/17 physical exam did not include a medical history. The physical examination shall include: A review of previous medical history. On , Individual # 1¿s medical history was sent to his Primary Care Physician for review (See Attached: Lifetime Medical History). A copy of Individual¿s lifetime medical history will be attached to each individual¿s annual physical form. 05/05/2017 Implemented
6400.144REPEATED VIOLATION- 5/16/16. On 11/14/16, Individual #1 was not administered the 9am dose of Acetazolomide, Lamotrigine, Docusate Sodium, Pilocarpine eye drops, and Cambigon eye drops. On 1/14/17, Individual #1 was not administered Docusate Sodium as prescribed by his/her physician. On 1/30/17, Acetazolomide was not administered to Individual #1. On 12/19/16, Individual #1 was prescribed Azelaic Acid 20% cream to be administered twice daily. The medication was not administered until 12/23/16.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All staff working in Briarcrest 1 will be retrained Medication Administration, which includes immediately documenting after each individual¿s does of medication is administrered. 05/05/2017 Implemented
6400.164(b)Individual #1 was prescribed a Z-pack to be administered for 5 days. The staff member administering the medication on 1/20/17 did not initial the medication log. The 9/18/16 administration of Doxycycline Hydrate was not initialed by the staff member adminsterting the medication. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff will be retrained in proper medication administration procedures. 06/30/2017 Implemented
6400.181(a)Individual #1's 4/1/17 assessment was not completed late. The previous assessment was completed on 2/1/16. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Our 6400.181 (a) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will provide supporting documentation that ISP review documentation was sent to all plan team members. The ISP review documentation will include how the plan team members were informed and the date the information was shared with all plan team members. Attachment #2 ¿ The Program Specialist will be responsible for the coordination and completion of Individual Assessments. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.181(e)(3)(i)Individual #1's 4/1/17 assessment did not include acquisition of functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. Our 6400.181(e)(3)(i) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly define and specify individuals supported current level of performance and progress in the following areas. See attachment # 3. Under, Acquisition of functional skills. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable of self-administration, he/she must be able to communicate the correct amount or pick up the correct amount of m 06/05/2017 Implemented
6400.181(e)(7)Individual #1's 4/1/17 assessment did not include his/her knowledge of heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Our 6400.186(d) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will provide supporting documentation that ISP review documentation was sent to all plan team members. The ISP review documentation will include how the plan team members were informed and the date the information was shared with all plan team members. Attachment #2 ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.181(e)(10)Individual #1's 4/1/17 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Our 6400.181(10) protocol has been updated and the following procedures have been instituted; ¿ Individual #1 assessment was update to add within the assessment the lifetime medical history. The standard assessment has been updated to include lifetime medical history information within the assessment document. See attachment #3 ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? 06/05/2017 Implemented
6400.181(e)(12)Individual #1's 4/1/17 assessment did not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Our 6400.181(12) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in personal adjustment. See attachment # 3. under Personal Adjustment ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable of self 06/30/2017 Implemented
6400.181(e)(13)(ii)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in motor and communication skills.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. Our 6400.181(13) (ii) protocol has been updated and the following procedures have been instituted; ¿ Individual #1 assessment was update to add within the assessment the lifetime medical history. The standard assessment has been updated to include lifetime medical history information within the assessment document. See attachment #3 ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be ta 06/05/2017 Implemented
6400.181(e)(13)(iii)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Our 6400.181(13) (iii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in personal adjustment. See attachment # 3. under Personal Adjustment ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable o 06/30/2017 Implemented
6400.181(e)(13)(iv)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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. Our 6400.181( e) (3)(iv) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in personal adjustment. See attachment # 3. under Personal Adjustment ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable 06/30/2017 Implemented
6400.181(e)(13)(v)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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. Our 6400.181(13 (v) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in Socialization. See attachment # 3. under socialization ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable of self-administ 06/30/2017 Implemented
6400.181(e)(13)(vi)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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. Our 6400.181( 13) (iv) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in Recreation. See attachment # 3. Under Recreation. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable of self-administrati 06/30/2017 Implemented
6400.181(e)(13)(vii)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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. Our 6400.181( e) (3)(vii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in Financial Independence. See attachment # 3. under Financial Independence ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered 06/30/2017 Implemented
6400.181(e)(13)(viii)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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. Our 6400.181(13) (viii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in Managing Personal Property. See attachment # 3. under Personal Property ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered cap 06/30/2017 Implemented
6400.181(e)(13)(ix)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include progress or regression over the past year in 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.Our 6400.181 (13) (ix) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in Community Integration. See attachment # 3. under Community Integration ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capab 06/30/2017 Implemented
6400.181(e)(14)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment did not include his/her ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Our 6400.181 (14) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in swimming. See attachment # 3. under Water Safety ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be considered capable of self-administration, 06/30/2017 Implemented
6400.181(f)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment was sent to team members on 4/5/17 for a 3/27/17 Individual Support Plan meeting.(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). Our 6400.181(f) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be provided with a central pa assessment date calendar as reminder of when individual¿s assessments are due. See attachment #7 ¿ The program specialist will provide the assessment to the SC and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.185(b)REPEATED VIOLATION- 5/16/16. Individual #1's Indiviudal Support Plan (ISP) included outcomes of health maintenance and community involvemnet. Neither outcome was implemented. Individual #1 was working on a goal of independence and safety. This outcome was not included in the ISP.The ISP shall be implemented as written.The goal was sent to the SC and requested to be to added to Individual #1's ISP. 06/30/2017 Implemented
6400.186(a)REPEATED VIOLATION- 5/16/16. Individual #1's 6/16/16 Individual Support Plan (ISP) Review was completed by Staff #2. Staff #2 is not a program specialist.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. Our 6400.186 (a) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be re-trained on the Program Specialist responsibilities. Target date of completion 06/30/2017. See attachment # 2 ¿ The Program Specialist will be responsible of completing and reviewing all individuals ISP reviews following the dates on each individual¿s ISP start date and end date. See attachment # 1. ¿ Person Responsible: Program Coordinator COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet DP 1) Start Date 06/06/16---- --to---- End date 09/05/16 Date completed; Date Signed; mailed to Team; 2) Start Date 09/06/16--- --- to----- End date 12/05/16 Date completed; Date Signed; mailed to Team; 3) Start Date 12/06/16--- to---- End date 03/05/17 Date completed; Date Signed; mailed to Team; 4) Start Date 03/06/17 ------ to----- End date 06/05/17 Date completed; Date Signed; mailed to Team; RW 1) Start Date 06/16/16-------- to----- End date 9/15/16 Date completed; Date Signed; mailed to Team; 2) Start Date 09/16/16-------- to----- End date 12/15/16 Date completed; Date Signed; mailed to Team; 3) Start Date 12/16/17-------- to------End date 03/15/17 Date completed; Date Signed; mailed to Team; 4) Start D 06/30/2017 Implemented
6400.186(b)REPEATED VIOLATION- 5/16/16. Individual #1's 3/16/17 Individual Support Plan Review was not signed and dated by the Individual or the program specialist. Electronic signature was provided on the ISP Review however the document was not created on a secured system. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Our 6400.186(b) protocol has been updated and the following procedures have been instituted; ¿ ISP review signature sheet updated to add a line for signature. See attachment# ¿ Program Specialist will provide a signature and/or a secure electronic signature to sign and date the ISP review signature sheet upon review of the ISP. ¿ Person Responsible: Program Coordinator/Program Specialist. 05/22/2017 Implemented
6400.186(c)(2)REPEATED VIOLATION- 5/16/16. Individual #1's 3/16/17, 12/16/16, 9/16/16, and 6/16/16 Individual Support Plan Reviews did not include a review of his/her seizure protocol and dental plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Our 6400.186 (c) (2) protocol has been updated and the following procedures have been instituted; ¿ ISP review form has been updated to capture additional protocols and/or plans. See attachment # Individual #1 does not have a specialized dental plan outlined in his current ISP. ¿ Person Responsible: Program Coordinator/Program Specialist. 05/20/2017 Implemented
6400.186(d)REPEATED VIOLATION- 5/16/16. There was no documentation to indicate the 12/16/16, 9/16/16, and 6/16/16 Individual Support Plan Reviews were sent to plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Our 6400.186(d) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will provide supporting documentation that ISP review documentation was sent to all plan team members. The ISP review documentation will include how the plan team members were informed and the date the information was shared with all plan team members. Attachment #2 ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.186(e)REPEATED VIOLATION- 5/16/16. Individual #1's plan team members were not given the option to decline the Individual Support Plan review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Our 6400.186(d) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will provide supporting documentation that ISP review documentation was sent to all plan team members. The ISP review documentation will include how the plan team members were informed and the date the information was shared with all plan team members. Attachment #2 ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.213(11)REPEATED VIOLATION- 5/16/16. Individual #1's 4/1/17 assessment indicated he/she uses a lip/plate gaurd during meal times. Individual #1's Individual Support plan indicated no adaptive equipment was needed when eating. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Our 6400.213(11) protocol has been updated and the following procedures have been instituted; ¿ Program Coordinator will notify individuals #1¿s SC to update the ISP to reflect the use lip plate/lip guard adaptive equipment during meal times. ¿ Program Coordinator will review the ISP every 3 months for content discrepancy and/or when a change is required to the ISP. ¿ Person Responsible: Program Coordinator/Program Specialist. 06/30/2017 Implemented
SIN-00094880 Renewal 05/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(2)Staff #1 became a program specialist in October 2015. Staff #1 was still not informed of their responsibilites as a program specialist at the time of licensing on 5/16/16.The program specialist shall be responsible for the following: Providing the assessment as required under § 6400.181(f) (relating to assessment). Our 6400.186(b) (2) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be re-trained on the Program Specialist responsibilities. Target date of completion 06/20/2016. See attachment # 2 ¿ The Program Specialist will be responsible of providing all duties relating to Individual Assessment as stipulated in 6400.181 (f). ¿ Target date of completion; 06/30/2016. ¿ Person Responsible: Assistant Residential Director and Program Specialist. 06/20/2016 Implemented
6400.46(i)Staff #2's date of hire was 7/16/15. At the time of licensing on 5/16/16, she still had not received training in cardio-pulmonary resuscitation. Staff #2 has worked many shifts independently. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. All staff will receive basic orientation and on-site orientation before working with individuals. A new orientation packet has been designed to include a basic orientation to be completed before the on-site orientation. The Program Coordinator will be responsible for overseeing completion of new staff orientation. The Employee Development Coordinator will be responsible for tracking and retaining new staff orientation packets. Employee Development Coordinator will ensure that CPR and 1st Aid training by a certified professional is offered to all staff on a quarterly basis. Staff who have not completed CPR by a certified professional within 6 months of hire will be removed from schedule, and considered for separation of employment. 06/20/2016 Implemented
6400.46(j)Record of training content was not kept for all trainings Staff #1 and #2 attended. Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The Employee Development Coordinator will retain records of all training content. Training without a copy of content will not be accepted. 06/20/2016 Implemented
6400.62(a)REPEAT: Individual #1's Whole Care peppermint toothpaste and Colgate Cavity Protection toothpaste were found in an unlocked and accessible cabinet in the hallway bathroom. Both of these items contained labels which read: "contact poison control center if ingested." The assessment for Individual #1 indicated that they cannot safely use or avoid poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. Our 6400.62 ( a) protocol has been updated and the following procedures have been instituted; ¿ Quality assurance check has been updated to include review of poisonous materials and the need to lock them if applicable and as per individuals Assessment. See attachment # 10. Item # 3. ¿ All staff will be trained on how to utilize the Quality assurance check list. Target date 7/30/2015. ¿ Person Responsible; Program Specialist. 06/20/2016 Implemented
6400.67(a)The shower located in Individual #1's master bathroom, contained 3 inches of rusted materials along the entire bottom of the shower. The sliding glass door leading to the porch would not open without difficulty. It got stuck and the use of an entire person's bodyweight was needed to open the door. Three to four foot black scuff marks were on the wall behind the kitchen table at chest height. The metal corner of the wall by the sliding glass door was exposed. Floors, walls, ceilings and other surfaces shall be in good repair. Our 6400.67 ( a) protocol has been updated and the following procedures have been instituted; ¿ Work order has been placed to have repairs to the shower, sliding door and kitchen wall. ¿ Floors, walls, ceilings and surfaces check has been added to our environmental check list. See attachment # 10, Item # 1 (b). ¿ All staff will be trained on how to utilize the environmental check list. ¿ Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.112(a)A fire drill was not held in Febuary 2016. An unannounced fire drill shall be held at least once a month. Our 6400.112 ( a) protocol has been updated and the following procedures have been instituted; ¿ A fire drill checklist and schedule has been formulated See attachment # 15. ¿ The Program Specialist will maintain the drill schedule and call staff on the day the drill is due to perform an unannounced fire drill. ¿ All staff will be trained on responsibilities during Fire drills. ¿ Quality assurance check list has been updated and will be reviewed daily. See attachment # 10. Item # 4. ¿ All staff will be trained on how to utilize the Quality assurance check list. ¿ Person Responsible; Program Specialist. ¿ Target date 7/15/2016. 06/20/2016 Implemented
SIN-00090518 Unannounced Monitoring 10/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32Individual #2 is being told she has to leave the home and go to Apartment #11 and sit there most of the day because of being short staffed. Individual #2 is also told to leave the home the dark to go to Apartment #11 so staff can give medications since there is not enough staff medication trained. Individual #2 has made it known to staff and others does not like walking in the dark or sitting at Apartment #11 all day which means Individual #2 is not able to go into the community to do disired activities. Individual #2 also does not like to get up early to have to go to this home.An individual may not be deprived of rights. The stated allegations from the direct care employee were reported and investigated see Incident # 8098807. The staff in the home have been trained in Medication Administration and have completed the certification process. The only exception is Staff # 2 due to her limited availability to complete the 2 remaining practicum observations. Community Interaction¿s HR team has developed a recruitment plan that is being implemented due to the staffing shortage. The plan includes but is not limited to; print job postings in multiple publications as well as electronic postings. The agency is also exploring contracting with a temporary staffing agency until permanent staff can be hired. 03/14/2016 Implemented
6400.46(a) Staff persons #1 & staff #2 both stated that when they had their initial orientation it was conducted in the homes of the Individuals. All parts of the orientation was conducted in the home while the Individuals where present. The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Moving forward all initial orientation training will take place in separate location from the individuals¿ residences.(P.S will be responsible for this training and documentation)JR 3/15/16 03/14/2016 Implemented
6400.62(a)The ISP for Individual #2 says poisons are to be locked in the home. During home inspection the following poisons where found unlocked- Sunscreen, body lotion, body sprays. These items where accessible to Individual #2. Poisonous materials shall be kept locked or made inaccessible to individuals. The assessment and ISP will be updated to note that Individual #2 can safely handle poisons in their home.(P.S will be responsible for tracking this documentation and implementation)JR 3/15/16 03/14/2016 Implemented
6400.141(a)The physical exam for Individual #1 was not completely yearly- 1/18/14 then not till 4/8/15An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Tracking of medical appointments will be done in Therap (web based electronic documentation system for I/DD service providers). Within 24 hours of each medical appointment, documentation from the appointment will be scanned and uploaded into Therap. The appointment summary will be reviewed to assure it will be completed and signed as required. Each subsequent appointment will be entered into Therap upon the scheduling of that appointment. Administrative personnel will have oversight of appointment through Therap to assure that all required appointments are scheduled and completed. 03/14/2016 Implemented
6400.141(c)(9)Individual #1's physical examination did not include a prostrate exam being completed. The physical examination shall include: A prostate examination for men 40 years of age or older. Tracking of medical appointments will be done in Therap (web based electronic documentation system for I/DD service providers). Within 24 hours of each medical appointment, documentation from the appointment will be scanned and uploaded into Therap. The appointment summary will be reviewed to assure it will be completed and signed as required. Each subsequent appointment will be entered into Therap upon the scheduling of that appointment. Administrative personnel will have oversight of appointment through Therap to assure that all required appointments are scheduled and completed. 03/14/2016 Implemented
6400.142(g)The dental hygiene plan for Individual #2 was not rewritten annually- The plan was completed 1/30/14 then not again until 9/14/15. A dental hygiene plan shall be rewritten at least annually. Tracking of medical appointments will be done in Therap (web based electronic documentation system for I/DD service providers). Within 24 hours of each medical appointment, documentation from the appointment will be scanned and uploaded into Therap. Each subsequent appointment will be entered into Therap upon the scheduling of that appointment. Administrative personnel will have oversight of appointment through Therap to assure that all required appointments are scheduled and completed. 03/14/2016 Implemented
6400.164(a)The following medications where not initialed on the medication log as given for Individual #2: 7/31/15-Polyethlene glycol 9pm, Clonazepam 9pm, Quetiapine Furnarate 9pm, Citalopram HBR 9pm, Topiramate 9pm & Cetiriene HCL 9pm. 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. Effective 3/21/16 Community Interactions will implement a documented daily overnight medication inspection to be completed by the Community Support Associate. The Program Specialist will also complete documented weekly medication inspections. 03/14/2016 Implemented
6400.181(d)The program specialist did not sign or date the annual assessment for Individual #2. The program specialist shall sign and date the assessment. Our 6400 181 (d) protocol has been updated and the following procedures have been instituted; An ISP/Assessment tracking sheet has been formulated to be completed by the Program Specialist and reviewed by the Assistant Residential Director by the 5th day of every month to ensure continued compliance of the 6400. 181 (d) regulations. (See attachment 1) 03/14/2016 Implemented
6400.181(e)(13)(ii)There was no progress and growth in motor and communication in the annual assessment for Individual #2. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(iii)There was no progress and growth in activities of residential living in the annual assessment for Individual #2. The information was the same as the prior year.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(iv)There was no progress and growth in personal adjustment in the annual assessment for Individual #2. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(v)There was no progress and growth in socialization in the annual assessment for Individual #2. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(vi)There was no progress and growth in recreation in the annual assessment for Individual #2. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(vii)There was no progress and growth in financial independence in the annual assessment for Individual #2. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(viii)This section- managing personal property was missing form the annual assessment for Individual #2. There was no progress or growth. 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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that includes a section on the individual's abilities in managing personal property (see attachment 3). 03/14/2016 Implemented
6400.181(f)The Program specialist did not provide the annual assessment for Individual #2 to all team members 30 days prior to the ISP meeting. (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). Our 6400.181(f) protocol has been updated to include an ISP/Assessment preparation checklist with the following step by step guidelines. 1) The Program Specialist will initiate and send out to the entire team, including the Supports Coordinator, an assessment 90 days prior to the end date of an existing plan. 2) When the individual and their Team members decide on an ISP date, if there is any needed for any updates in the assessment the Program Specialist will provide the updated assessment to the SC and all team members. This will be done at least 30 days prior to the ISP meeting to enable the development of the ISP, the annual update and revision of the ISP. 3) The protocols will be used in conjunction with the ISP /Assessment tracking sheet attached (see attachment 1). 03/14/2016 Implemented
6400.186(a)The Program Specialist did not complete an 3 month ISP review in September 2015 for Individual #2.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. Our 6400.186(a) protocol has been updated and the following procedures have been instituted; An ISP/Assessment tracking sheet has been formulated to be completed by the Program Specialist and reviewed by the Assistant Residential Director by the 5th day of every month to ensure continued compliance of the 6400. 181 (a) regulations. (See attachment 1) 03/14/2016 Implemented
6400.186(b)The Program Specialist did not sign or date the following ISP reviews: 6/10/15,3/11/15,12/11/14 for Individual #2. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Our 6400.186(b) protocol has been updated and the following procedures have been instituted; An ISP/Assessment tracking sheet has been formulated to be completed by the Program Specialist and reviewed by the Assistant Residential Director by the 5th day of every month to ensure continued compliance of the 6400.181(b) regulations. (See attachment 1). At the due date of each ISP review the Program Specialist will submit completed ISP Review for final review by the Assistant Residential Director prior to final filling to ensure continued compliance of the 6400 181 (b) regulations. 03/14/2016 Implemented
6400.186(c)(2)The Program Specialist did not review the Dental Hygiene plan that is in place in the ISP for Individual #2. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Tracking of medical appointments will be done in Therap (web based electronic documentation system for I/DD service providers). Within 24 hours of each medical appointment, documentation from the appointment will be scanned and uploaded into Therap. The appointment summary will be reviewed to assure it will be completed and signed as required. Each subsequent appointment will be entered into Therap upon the scheduling of that appointment. Administrative personnel will have oversight of appointment through Therap to assure that all required appointments are scheduled and completed. 03/14/2016 Implemented
6400.186(e)The program specialist did not notify the plan team members of the option to decline the ISP review documentation for Individual #2. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Our 6400.186 (e) protocol has been updated and the following procedure has been instituted; An option to decline letter will be sent out to team members with each ISP review upon due dates (see attachment 2) 03/14/2016 Implemented
SIN-00074482 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)The physical exam completed on 9/5/14 for Individual #1 stated NKA in the allergy section. The ISP stated Individual #1 is very allergic to bee stings and requires Benadryl to be administered immediately and contact doctor.The physical examination shall include: Allergies or contraindicated medications.Our 6400.141 (c13) protocol has been updated and the following procedures have been instituted: ¿ Our Medical Visit Summary Form that accompanies an individual to all medical appointments has been updated to include the listing of an individual¿s Allergies. The signature of the physician will acknowledge the Allergy exists and necessary tests and protocols for safety as needed. ¿ Confirmed allergies for all individuals will be shared to the individuals team and the information added into the individuals ISP (see attachment 6-hard copy to follow) 05/30/2015 Implemented
6400.151(a)Staff person #1 did not have a current physical exam. Last physical exam was 6/12/12; there should have been one completed 6/14. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Our 6400.151 (a) protocol has been updated and the following procedures have been instituted: ¿ A tracking system has been instituted to include all Physical examinations and Mantoux test for all staff. Individual staff members will keep a personal record for themselves and Community Interactions Human Resources will maintain a master record (Please see attachment 5-hard copy to follow). ¿ In addition, Human Resources Department will send out reminders of due dates as they approach to ensure bi-annual Physicals follow up for all staff members remain current 05/30/2015 Implemented
6400.151(c)(2)Staff person #1 did not have a Mantoux test completed every 2 years. Last Mantoux was completed 6/18/12; there was no Mantoux completed for 6/14. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Our 6400.151 (c2) protocol has been updated and the following procedures have been instituted: ¿ A tracking system has been instituted to include all Physical examinations and Mantoux test for all staff. Individual staff members will keep a personal record for themselves and Community Interactions Human Resources will maintain a master record (Please see attachment 5-hard copy to follow). ¿ In addition, Human Resources Department will send out reminders of due dates as they approach to ensure bi-annual Physicals follow up for all staff members remain current. 05/30/2015 Implemented
6400.164(a)Individual #1's medication log for Aug 11, 2014 Zaditor antihistamine eye drops were administered there was no time that it was administered. May 16, 21 and 30th Ketotifen eye drops where administered but no time was listed on the medication log. April 4 & 5, 2014 Ibuprofen was administered, but no time was listed on the medication log. April 2 & 6, 2014 Tussin DM cough syrup was administered, but no time was listed on the medication log. 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. Our 6400.164 (a) protocol has been updated and the following procedures have been instituted: ¿ Staff will be retrained on the State requirement of administration and documentation of as needed medication. ¿ The training will include a review of the Medication log requirements of all medications an individual takes to include all prescribed medications, dosage, time, date, and staff signatures and initials. ¿ An overnight medication administered review checklist will be completed by the overnight staff daily to ensure all medications were administered as prescribed. In case of any concerns, the overnight staff will report the issues or concerns to the On Call Administrator (Please see attachment 4-hard copy to follow). 05/30/2015 Implemented
6400.168(c)The current medication trainers- Staff #2 certificate expired 12/13 but currently has been training other staff. 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. Our 6400.168(c) protocol has been updated and the following procedures have been instituted; ¿ An Annual Medication Trainer Tracking Sheet has been instituted. (See attachment 2-hard copy to follow). ¿ All Medication trainers will be trained on how to utilize the Annual Medication Trainer Tracking Sheet. ¿ The Annual Medication Trainer Tracking Sheet will be reviewed annually and signed by all Medication Trainers. ¿ The signed Annual Medication Trainer Tracking Sheet will then be filed with the Medications Trainers Annual Practicum Recertification package. Twelve months prior to expiration of the Medication Trainers certification, the medication trainer will proceed and sign up for the recertification class using the Department of Social Services/ Department of Public Welfare guidelines. 05/30/2015 Implemented
6400.181(d)The annual assessment 2/1/14 for Individual #1 was not signed or dated by the program specialist- Staff #2The program specialist shall sign and date the assessment. Our 6400.181(d) protocol has been updated and the following procedures have been instituted; ¿ A Signature Sheet has been instituted to be signed upon the review of all Assessment by both the Individual supported and the Program Specialist (See attachment 2-hard copy to follow). ¿ The Signature Sheet will them be filed together with the Assessment in the individuals records. 05/30/2015 Implemented
6400.181(f)The annual assessment 2/1/14 for Individual #1 was not sent to the team members 30 days prior to the ISP.(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). Our 6400.181(f) protocol has been updated and the following procedures have been instituted: ¿ The Program Specialist will initiate and send out to the entire team, including the Supports Coordinator, an assessment 90 days prior to the end date of an existing plan. ¿ When the individual and their Team members decide on an ISP date, if there is any needed for any updates in the assessment the Program Specialist will provide the updated assessment to the SC and all team members. This will be done at least 30 days prior to the ISP meeting to enable the development of the ISP, the annual update and revision of the ISP. ¿ Documentation showing the Assessment was sent out 30 days prior to the ISP meeting will be filed in the individual¿s records. (See attachment 3-hard copy to follow) 05/30/2015 Implemented
6400.183(5)The ISP for Individual #1 states in the Behavior Section "The team is currently working on re vamping the BSP once completed the new plan will be added ( 4/8/14) ISP .' The BSP that in the record has not changed (6/16/14) or added to the ISP yet. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. Our 6400.183(5) protocol has been updated and the following procedures have been instituted; ¿ Our Assessment has been updated to include the review of an individual¿s Behavior Plan as needed or at least annually and within 90 days prior to the an individual¿s ISP meeting. (See attachment 2-hard copy to follow) ¿ The Signature sheet will then be filed together with Individual supported Assessment. 05/30/2015 Implemented
6400.186(b)Individual #1 did not sign the 9/15/14 ISP review. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Our 6400.186(b) protocol has been updated and the following procedures have been instituted; ¿ A Signature Sheet has been instituted to be signed upon the review of all ISP¿s by both the Individual supported and the Program Specialist (See attachment 2-hard copy to follow). ¿ The Signature Sheet will them be filed together with the ISP in the individuals records. 05/30/2015 Implemented
SIN-00058967 Renewal 11/12/2013 Compliant - Finalized