| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home did not have the date documented of when the assessment was completed, it therefore cannot be determined if it was completed within 3-6 months prior to the expiration date of the certificate of compliance. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The self-assessment for the Ivy Group Home was completed 1/8/21 (sent separately) with action items corrected and attached. With the departure of the assigned Associate Director, it was not found until January that the self-assessment needed to be completed. A fill-in supervisor at Ivy assisted a Program Specialist (from another team) and Director with necessary corrections. |
07/07/2021
| Implemented |
| 6400.15(c) | The Self-assessment had a list of corrections that needed to be completed, however they did not contain the written summary of corrections that were made to the list of identified items that needed corrected or the dates the items were corrected. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The original self-assessment was prepared by an Assoc. Dir., who left the company; the written summaries of the corrections could not be located. The Program Specialist and current Associate Dir. completed any needed action items and provided documentation of completed action items. Documentation for each program is submitted separately. |
07/12/2021
| Implemented |
| 6400.22(d)(2) | Individual #1's financial ledger documented that the ending amount of funds from March 2021 was $195.00, however the beginning Ledger for the month of April 2021 documents the beginning balance was recorded as $195.16. This caused the whole next month of April to be off by 16 cents for the whole month. The ending April balance should be $86.99, not $87.15. This error was not caught in the month of May 2021 either or the beginning of June of 2021. | (2) Disbursements made to or for the individual.
| Immediate correction entailed fixing the ACA envelope to reflect the proper dollar amount, which was done 6/23/21.The 'Procedures for Managing Individual's Finances' was revised to reflect additional oversight - the Program Supervisor will perform a weekly audit of the ACA balance [p.3, #10]. Additionally, each month when the Residential Admin. Secy reviews the ACA's for accuracy, she will follow-up with an email to the Program Supervisor, Program Specialist and Associate stating what the correct balance is for the new month [p.4, #13]. |
07/01/2021
| Implemented |
| 6400.142(a) | Individual #1 had a dental appointment on 7/15/2019 and not again until 3/18/21. There was no routine dental visit in 2020 or documentation demonstrating that an attempt to make a dental visit in 2020 occurred. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Documentation does not exist in the individual's record regarding attempts made to schedule dental appointments in 2020. Although dental offices were closed and not accepting appointments for a portion of the 2020 year, staff did not make attempts to schedule appointments, or if they did, there is no record of those attempts. (additional dental reviews/timeline sent separately). Between the Program Supervisor stepping down, the Program Specialist leaving the company and the arrival of a new Program Specialist in late 2020, it is not possible to recreate what steps were taken, if any, to rectify the dental situation. The individual did have a dental appointment on 3/18/21 for 2 extractions, and his 6-month appointment is scheduled for 9/30/21. |
07/09/2021
| Implemented |
| 6400.142(g) | There was no dental hygiene plan in individual #1's chart from 2020 or 2021. | A dental hygiene plan shall be rewritten at least annually. | Individual did not have a dental appointment between 9/19 and 3/21. As a result the dental hygiene plan was not rewritten annually. Dental hygiene plan has been verified, the Protocol updated and update sent to the Supports Coordinator to update the ISP, Training sign-in sheet for staff re: dental hygiene protocol also submitted. (sent separately). The plan is in the record. |
07/07/2021
| Implemented |
| 6400.142(h) | There was no dental hygiene plan in individual #1's record. | The dental hygiene plan shall be kept in the individual's record. | Individual did not have a dental appointment between 9/19 and 3/21(see violation 6400.124(g) for details), therefore there was not a current plan in the individual's record. The dentist was contacted by the Program Specialist and confirmed the dental hygiene plan for the individual. The next dental appointment has been scheduled for 9/30/21. The individual did have 2 extractions done on 3/30/21. ISP updates were sent to the SC, a Dental Hygiene Plan and Protocol was written and staff were trained. Documents are in the individual's record. |
07/07/2021
| Implemented |
| 6400.216(a) | Individual #1's records, that contained personal identifying information such as physicals, BM charts, Seizure charts, etc. were located on a shelf in the dining room. They were unlocked and unattended at the time of inspection. | An individual's records shall be kept locked when unattended.
| During the inspection, when it was found that an individual's records were not locked and were left unattended, they were immediately taken to the office where they were locked in the locking medicine cabinet; Additionally the office door is locked when staff are not inside of it. The staff at that program were made aware that having the records unlocked and close by, for their convenience, is not appropriate and cannot occur again. |
07/07/2021
| Implemented |