|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | REPEAT from 10/16/19 annual inspection: The concrete front porch is cracked and has sunken approximately two inches from the original attachment point, creating a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Estimate was obtained on 11/9/20 for construction of gable roof and porch front at front door. Construction of 205 Elim porch will begin as soon as weather permits. Estimated date of completion 4/30/21. See Attachments #1a and #1b |
04/30/2021
| Implemented |
| 6400.80(b) | The window wells in the front of the house are filled with yard waste and lint from the clothes dryer. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Window wells were cleaned out on 8/28/20 by Landscaping and will be cleaned as needed. Program Supervisor will monitor the window wells weekly. If window wells need cleaned, Supervisor will contact Landscaping to have them cleaned out. See Attachments: #2a and #2b |
08/28/2020
| Implemented |
| 6400.34(a) | The Department issued updated individual's regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. The most recent review of Individual #1 rights was on an agreement created on January 1, 2020, purported to have been signed by Individual #1 on November 27, 2019. | 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. | Individual Regulatory Rights were updated on 10/21/2020 to include all the rights according to regulations. Individual Rights were reviewed will all individuals in the agency. See attachments: # 3 pages numbered 1 - 8 |
12/08/2020
| Implemented |
| 6400.169(d) | At the time of the 8/26/2020 annual inspection, Staff person #1 has been administering medications to individuals for a few months. However, a medication trainer did not document on the staff's initial practicum summary that the course was successfully completed, a date of completion, or the medication trainer's name that completed and reviewed Staff person's #1's initial medication administration training.
Medication trainer, Staff person #3, did not document her signature and date on Staff person #2's 10/8/19 annual medication administration training documents; the practicum summary form, two medication administration record reviews, and two medication observation reviews. Staff person #3 only recorded her electronic, typed name and electronic date of completion for the said documents. The electronic system used to document dates and signatures was not a secure system that required the author to have specific credentials to complete Staff person #2's medication training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Staff person #1 completed the last two of the required four medication administrations, for the initial practicum, on 6/2/20. The final two medication administrations were documented on the medication administration sheets; however, it was not documented on the initial practicum summary. The medication trainer responsible for the medication administrations, completed by Staff #1, documented these two administrations on the initial practicum summary on 9/29/20 and documented it as a late entry, along with the trainers initials (see 3rd attachment). Staff person #1 did not administer any medications after the 6/2/20 administrations. All other medication administration packets were reviewed by medication trainer for completion on 12/8/20. No other errors/omissions were found. The entire medication packet, for all staff administering medications, will be reviewed twice yearly along with the required medication administration observations to ensure it is completed in its entirety. See Attachments: #4a, #4b and #4c.
Staff person #3 will ensure with each medication administration review and medication observation review are signed and dated, verifying the training at the time of the review. All medications trainers were trained to follow 6400.169(d). See attachments: # 5a, #5b, #5c, #5d, #5e and #5f. |
12/08/2020
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Ceiling in the basement room used as a personal gym was missing tiles. | Floors, walls, ceilings and other surfaces shall be in good repair. | Estimate from contractor was received 11/13/2014 and work is to be completed in January 2015 |
01/30/2015
| Implemented |
| 6400.74 | Steps off of back deck did not have nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Non skid strips were placed on both sets of steps off back porch. Refer to attachments #12 and #13. (Pictires of non-skid surfaces on steps) |
10/27/2014
| Implemented |
| 6400.141(c)(6) | Individual #1 had tuberculin skin testing on 9/7/2012 and then did not have one within the 2 year time frame. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Staff were trained on physicals and TB tests by the Program Specialist. See attachments #9, #10 and #11. The Program Specilist comprised a checklist of all individuals and reviewed all physicals for up to date TB tests. See attachment 10a. The Program Specialist will monitor all physicals to assure TB tests are completed in a timely manner.
|
11/17/2014
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment did not show progress and growth in socialization over the last 365 calendar days. | 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. | Program Specialists and Supervisors were trained by the Executive Director on the revisions on the assessment to include progress and growth in socialization. See attachments #7 and #8. The Program Specialist reviewed all records to assure the information is present in all assessments. See attachment 8b. The Program Specialist will monitor individual assessments to assure compliance using the checklist. |
11/17/2014
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment did not show progress and growth in recreation over the last 365 calendar days. | 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. | Program Specialists and Supervisors were trained by the Executive Director on the revisions on the assessment to include progress and growth in recreation. See attachments #7 and #8.The Program Specialist reviewed all records to assure the information is present in all assessments. See attachment 8b. The Program Specialist will monitor individual assessments to assure compliance using the checklist. |
11/17/2014
| Implemented |
| 6400.217 | Individual #1's record did not include a consent to release information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Program specialists and Supervisors were trained by Executive Director to assure eachindividual record has consent to release information on file. A checklist of individuals was comprised for the Program Specialists to assure all individual files are compliant. Refer to attachments #1 through #6. Program specialists will monitor that each individual record will include consent forms by utilizing the attached checklist. |
11/17/2014
| Implemented |
|
|