| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The fire extinguisher located in the basement of the home has not been inspected since February 2012. | (f) A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.
| ADEQUATE PROGRESS
The fire extinguisher was inspected and approved by a fire safety expert on 11/19/13. See Attachment #4. The home safety inspection checklist was updated to include confirming that the date of the inspection of each fire extinguisher is current for all agency fire extinguishers. Staff will conduct the safety survey in each home on a monthly basis and the survey will be reviewed monthly by the Chairman of the Safety Committee. See Attachment #5
picture of fire extinguisher and tag sent on 3/6/14 to validate plan. AH |
01/31/2014
| Implemented |
| 6400.144 | Individual #1 has a seizure disorder. On February 25, 2013 and June 3, 2013, Individua1 #1 had a seizure lasting between 5 and 6 minutes. There is no seizure protocol for staff to follow when a seizure is occuring. There is no information on file telling staff what to do when a seizure lasts longer than a certain time. | 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.
| ADEQUATE PROGRESS
Protocol to deal with an individual who is diagnosed with a seizure disorder has been obtained from their Neurologist. This protocol has become a part of the individual¿s emergency medical file, main file and the substitute aid book. A copy of this has also been placed with the medication administration records. See Attachment #6. A policy is being developed to ensure all persons with in the group homes provided for by Cambria Residential Services, will have their health service needs met. See Attachment #7. |
01/31/2014
| Implemented |
| 6400.151(c)(3) | The physical for Staff #2 did not indicate if the staff member was free of communicable diseases. | (3) A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals.
| The health care provider temporarily substituted a form for physicals conducted during the short period when T.B. tests were not available and then called staff back in for the test and sent the correct physical reports. The health care provider will notified that only the form that meets our regulations is acceptable at all times and our secretary will be instructed not to accept any non-compliant physicals but to notify that the executive director and health care provider of any non-compliant reports. The Executive Director will monitor to ensure that corrective action is effective. See attachment # 8.
a recently completed physical was sent on 3/6/14 to validate plan. AH |
01/31/2014
| Implemented |
| 6400.164(a) | Individual #1 was prescribed Lyrica 75mg for 3 days, one week off, 75mg for another 3 days, one week off, and then 150mg for 3 days. Lyrica 150mg was not written on the medication log as a new medication being prescribed. Instead, it was included in the Lyrica 75mg medication log with an arrow stating they medication had switched to the higher dosage. | (a) 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.
| ADEQUATE PROGRESS
The staff who work at the home where this documentation error was discovered were retrained on medications administration on 12/04/13. See Attachment #9. Also on a monthly basis medication logs will be reviewed by a supervisor for any possible detectable errors. A record review form will be completed and attached to those administration forms prior to filing. These record reviews will be monitored by the Director of Quality Management. See Attachment #10. All Supervisors who review the MARS will be trained by the medication supervisors as to what may be errors and way to systematically review these MARS. See Attachment #11. Attachment #22 used in validating this plan. AH. |
01/31/2014
| Implemented |
| 6400.165 | On September 11, 2013, Carbamazepine 10mg, Oyster Shell 400mg, Baclofen 20mg, and Docusate Sodium 100mg were not signed off as being administered to Individual #1. There was no documentation of the medication errors kept on file. The errors were not reported in HCSIS.
Ear Drops 6.5% are to be administered once a week on Saturdays at noon. Ear drops were not signed off as being administered on 2/2/13, 2/9/13, and 2/16/13. There was no documentation on file or the medication errors. Medication errors were not reported in HCSIS.
Docusate Sodium 100mg and Ear Drops 6.5% were switched on the medication log. Staff were signing off on the Docusate Sodium in the Ear Drops section on the medication log. An arrow was written on the log indicating the two were switched. When the error was noticed (February 18), Docusate Sodium was rewritten on the medication log and signed off as being administered correctly. There was no documentation on the medicaion log indicating a documentation error.
| Documentation of medication errors and follow-up action taken shall be kept.
| ADEQUATE PROGRESS
HCSIS reports were filed on 11/20/13. See Attachments #13, #14 & #15. Staff were retrained on medications administration, proper documentation of administration, and reporting procedure when an error is suspected. See Attachment #12. Also on a monthly basis medication logs will be reviewed by a supervisor for any possible errors. A record review form will be completed and attached to those forms prior to filing. See Attachment #10. |
01/31/2014
| Implemented |
| 6400.181(e)(7) | The assessment for Individual #1 does not include the awareness of heat sources and ability to move away. | (7) 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.
| ADEQUATE PROGRESS
The Assessment Tool will be revised to include the individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees f and are not insulated. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16. |
01/31/2014
| Implemented |
| 6400.181(e)(12) | The assessment for Individual #1 did not include recommendations for specific areas of training, programming, and services. | (12) Recommendations for specific areas of training, programming and services.
| ADEQUATE PROGRESS.
The Assessment Tool will be revised to include recommendations for specific area of training, programming and services. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16.
|
01/31/2014
| Implemented |
| 6400.181(e)(13)(i) | The assessment for Individual #1 did not include progress and growth over the last 365 days in Health, Motor and Communication, Activities of Residential Living, Personal Adjustment, Socialization, Recreation, Financial independence, Managing personal property, and community integration. There was no section in the assessment for community integration. | (13) The individual's progress over the last 365 calendar days and current level in the following areas:
(i) Health.
(ii) Motor and Communication. (iii) Activities of residential living. (iv) Personal Adjustment. (v) Socialization. (vi) Recreation. (vii) Financial independence. (viii) Managing personal property. (ix) community integration. | ADEQUATE PROGRESS
The Assessment Tool will be revised to include the individual¿s progress over the last 365 calendar days and current level in the following area: (i) Health, (ii) Motor and Communication, (iii) Activities of residential living, (iv) Personal Adjustment, (v) Socialization, (vi) Recreation, (vii) Financial independence, (viii) Managing personal property, (ix) community integration. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16. |
01/31/2014
| Implemented |
| 6400.181(e)(14) | The assessment for Individual #1 did not indicate the ability to swim. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim.
| ADEQUATE PROGRESS
The Assessment Tool will be revised to include the individual¿s progress over the last 365 calendar days and current level in the following areas: (14) The individual¿s knowledge of water safety and ability to swim. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16. |
01/31/2014
| Implemented |
| 6400.183(7)(iii) | The ISP for Individual #1 did not indicate the potential to advance in vocational programming. | (7) Assessment of the individual's potential to advance in the following: (iii) Vocational programming.
| INADEQUATE PROGRESS
The Assessment Tool will be revised to include the individual¿s potential to advance in the following: (iii) Vocational programming. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16. This information is forwarded to the Supports Coordinator 30 days prior to the ISP meeting. This is to guide the SC, as the ISP is to flow from the assessment of the individual. Upon receipt of the completed ISP the Program Director will review and document the review. If the information regarding the above is not completed adequately the SC will be notified via email.
validation material not sent to validate plan. additional information requested on 3/3/14 and was not sent. AH |
03/31/2014
| Implemented |
| 6400.183(7)(iv) | The ISP for Individual #1 did not state the potential to advance in competitive employment. | (7) Assessment of the individual's potential to advance in the following: (iv) Competitive community-integrated employment.
| INADEQUATE PROGRESS
The Assessment Tool will be revised to include the individual¿s potential to advance in the following: (iv) Competitive community-integrated employment. The Executive Director will be responsible for ensuring that an updated assessment tool is developed. See Attachment #16. This information is forwarded to the SC 30 days prior to the ISP meeting. This is to guide the SC, as the ISP is to flow from the assessment of the individual. Upon receipt of the completed ISP the Program Director will review and document the review. If the information regarding the above is not completed adequately the SC will be notified via email.
sent email on 3/3/14 requesting more information for citation. validation material was sent however was not correcting the noncompliance. AH |
03/31/2014
| Implemented |