| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist did not completed Individual #1's assessment. Direct care staff and home supervisors whom were not qualified to perform program specialist duties, were completing the assessments for individuals. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | As an agency we have been utilizing information that direct care staff and the Supervisor at each location gathered since they work each day directly with the individuals. The Program Specialist was then reviewing, and adding any other needed information. We will now have the Program Specialist complete all parts of the assessment process effectively immediately. A memo has been sent to all Program Specialists and Associate Directors regarding this change.(see memo). |
04/19/2016
| Implemented |
| 6400.62(a) | REPEAT: Individual #2 was not aware of how to use or avoid poisonous materials. Many substances with a label to contact poison control center if injested were found unlocked throughout the home. Some of those substances included Care One Antibacterial foaming soap that was in all 3 bathrooms. Five different deoderants including Speed Stick and Secret roll on gell were unlocked in the first full bathroom by Individual #1's bedroom. In that same bathroom there was toothpaste and Dermasil Lotion. The back full bathroom contained numerous containers of soaps, shampoos, conditioners, and lotions that were not locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Each individual's ISP and Assessment, has been updated to verify their ability to recognize and properly use the items listed including the Care One Antibacterial soap, and deodorants, toothpaste, Dermasil lotion, shampoo, conditioner, and lotions. (see addendums) |
04/11/2016
| Implemented |
| 6400.67(a) | More than 10 black stains were covering the carpet in the living room, hallway, and surrounding floor space. Some stains were 2 inches in diameter, some were long and narrow with over a foot in length. | Floors, walls, ceilings and other surfaces shall be in good repair. | We have selected a company to replace the carpeting and flooring in the areas mentioned above. We had planned to do this in our next fiscal year, but have decided to move forward with the replacement now. We were aware of the issue, and staff have been cleaning the spills whenever the individual has spilled drinks, but the stains do not come out any longer.(See letter from flooring company regarding replacement plan) |
05/11/2016
| Implemented |
| 6400.77(b) | The first aid kit did not contain tweezers. | 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 tweezers were located in the van, and were returned to the first aid kit.
A memo was sent to staff reminding them that they must return all items to the first aid kit after use.
A spare set of tweezers was also purchased to avoid a repeat of this issue. |
04/11/2016
| Implemented |
| 6400.144 | On 9/10/15, Individual #1's psychiatrist requests lab work be completed to measure their LFT and Depakote levels. The labe work was not completed until March 2016. | 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.
| A memo was sent to staff to assure that before staff leave doctor appointments of any kind, they double check to make sure they have all orders for work requested by the doctor. When we have another appointment completed with lab orders sent along, we will forward that documentation along with results from the lab work to complete our documentation. |
04/11/2016
| Implemented |
| 6400.164(b) | On 2/4/16 Individual #1 was prescrived Augmenton 10ml, twice a day for 10 days. Staff explained that Individual #1 received the first dose at 7pm on 2/4/16 however, the direct care staff working that shift, forgot to sign the medication administration record. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | All program staff had a "Medication Administration Observation" completed, and a memo was sent to the program reminding all staff to initial the medication administration record as soon as they administer any medication. We will submit an appointment review with current MAR attached to complete our documentation as soon as an individual has an appointment. |
04/15/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's 10/22/15 assessment did not contain their progress 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. | An addendum to the assessment was written by the Program Specialist to address this area, and was sent to all team members. |
04/11/2016
| Implemented |
| 6400.186(a) | The program specialist did not complete Individual #1's Individual Support Plan (ISP) reviews. Direct care staff and home supervisors, whom were not qualified to perform program specialist duties, were completing the assessments for individuals. | 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. | A memo was sent to all Program Specialists and Residential Supervisor's clarifying the role that must be fulfilled by the Program Specialist in writing the quarterly ISP reviews. We have corrected our procedures and will no longer allow the direct care staff and Residential Supervisors to complete a first draft of these documents. |
04/19/2016
| Implemented |
| 6400.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews did not review their participation and progress during the prior 3 months towards their outcome to wear a pedometer to increase their strength and stamina. Their ISP reviews also did not not include a review of the residential-health outcome to work on volunteering. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | A memo was written, and Program Specialists will receive further training on what must be included in the ISP reviews regarding the individual's participation and progress toward their outcomes supported by the residential home (on 4/28/16). We will submit an upcoming ISP review with detailed information regarding an individuals participation and progress toward an outcome when one is due. |
04/28/2016
| Implemented |
| 6400.216(a) | Individual #1's old record information from 2007 was stored in the basement, unlocked. Other individual record information for an individual who passed away recently, was stored in the basement unlocked as well. | An individual's records shall be kept locked when unattended. | All old records that were stored in the basement of this home have been moved to our secure storage facility.
A memo was sent to all staff to remind them of the necessity of keeping all individual's records locked when unattended. |
04/19/2016
| Implemented |