| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | Individuals attending the program today, 5/31/17, were unable to evacuate the building within 2 1/2 minutes. It took the individuals 2 minutes and 50 seconds to evacuate the building. The facility did not have an extended evacuate time specified in writing within th epast year by a firesafety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Regarding regulation 2380.89(d) Director and Activity Coordinator/Supervisor were retrained on this area. (Att. 4) A new fire drill was completed on 6/14/17. (att. 13). Staff and clients have completed and will continue to complete informal and formal training and fire safety reviews. A formal quarterly fire safety training [was held on 6/20 with staff and clients. ] (att. 14) Going forward Director and Activity Coordinator/Supervisor will continue to work with staff and clients at each monthly fire drill to ensure a smooth traffic flow and 2 exits are utilized whenever feasible Ongoing quarterly training will continue to stress the importance of safety issues. |
06/30/2017
| Implemented |
| 2380.111(c)(1) | REPEAT from 5/27/16 annual inspection: Individual #1's 4/4/17 physical examination form did not include a review of his/her previous medical history. | The physical examination shall include: A review of previous medical history. | Regarding regulation 2380.111(c)(1) the Director requested a lifetime medical history for individual #1 be submitted to his physician for review and return to us to attach to his physical on file (att 9 and 10). PS and Director and LPN were retrained on this regulation (att. 4) Director will review all physicals to ensure lifetime medical histories are attached and reviewed by 6/30/17. Going forward a physical checklist will be completed upon receipt of each physical. (Att 11) |
06/30/2017
| Implemented |
| 2380.111(c)(3) | Individual #2's 2/7/17 physical examination form did not include documentation of Diphtheria and tetanus shot. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Regarding regulation 2380.111(c)(3) a copy of client #2¿s most recent tetanus shot was obtained from the doctor and attached to his physical. (att 12) Director, PS and LPN were retrained on this regulation. (att 4). Director will review all files to ensure tetanus and diphtheria shots are listed and current on physicals by 6/30/17. Going forward a physical checklist will be completed upon receipt of each physical.(att.11) |
06/30/2017
| Implemented |
| 2380.111(c)(4) | Individual #2's 2/7/17 physical examination form did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | Regarding regulation 2380.111(c)(4) a letter from individual #2s doctor addressing a hearing and vision screening was obtained and added to his physical. (att. 12). Director PS and LPN were retrained on this regulation. (att. 4) Director will review all files to ensure hearing and vision is addressed on each physical by 6/30/17. Going forward a physical checklist will be completed upon receipt of each physical. (att. 11) |
06/30/2017
| Implemented |
| 2380.111(c)(9) | REPEAT from 5/27/16 annual inspection: Individual #1's allergy to Soothe XP eyedrops was not indicated on his/her 4/4/17 physical examination form. | The physical examination shall include: Allergies or contraindicated medication. | Regarding regulation 2380.111(c)(9) applicable allergies were noted on individual #1s physical form. (att. 10). Director, PS and LPN were retrained on this regulation. (att. 4) Director will review all files to ensure allergies are noted on all physicals by 6/30/17. Goring forward a physical checklist will be completed upon receipt of each physical. (att. 11) |
06/30/2017
| Implemented |
| 2380.128(a) | Staff #1's medication administration certification froms, medication audits and observations, were completed by a practicum observer who was not certified to be a practicum observer. Thus Staff #1 was not certified to pass medications. The forms completed for Staff #1's certification were not the annual medication training certification forms, they were initial practicum observer forms. | A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Regarding regulation 2380.128(a) staff #1 will no longer pass medication until she has retrained and passed the Department¿s Medications Administration Course. Life Time¿s LPN will pass all medications until staff #1 or other LT staff have been trained or retrained and have passed the Department¿s Medication Administration Course. Training certifications will be submitted upon completion of the MA course. Going forward all Med Trained staff will be retrained annually. Documentation will be kept and follow the guidelines of the Department¿s Med Admin Course. |
07/28/2017
| Implemented |
| 2380.128(c) | Staff #2 had passed her initial practicum observer certification in July 2010. She has not had a recertification completed since then. Staff #2's file indicated that her annual medication administration training to pass medications was also her annual medication practicum observer certification. Staff #1's current medication administration certification froms, medication audits and observations, were completed by "practicum observer" Staff #2, who was not certified to be a practicum observer. | Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons. | Regarding regulation 2380.128(c) Staff #2 will retrain and complete the Practicum observer course or the Train the trainer course in order to appropriately review and instruct all med trained staff on an ongoing manner. Training certification will be submitted upon completion. Life Time will utilize another certified med trainer within CPARC to monitor and review med administrators as required until staff #2 is certified. |
08/31/2017
| Implemented |
| 2380.128(e) | Documentation of Staff #1's medication administration observations were not kept. Documentation of all staff's medication administration audits and observations were not kept for the current, completed year of certification. The medication administration audtis that were completed for staff's annual medication administration certification were practicum observer forms. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | . Regarding regulation 2380.128(e) going forward all documentation will be maintained as outlined. Director retrained on this regulation. (att. 4). |
06/23/2017
| Implemented |
| 2380.181(e)(3)(iii) | Individual #1's 4/5/17 assessment did not include their current level of performance and progress in personal adjustment. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal adjustment. | Regarding regulation 2380.181.e3iii the program specialist updated Individual #1¿s annual assessment by addendum. (att. 6) to include a current level of performance and progress in personal adjustment. PS and Director were retrained on this regulation (att. 4) Director will review all assessments to ensure inclusion of current levels of performance and progress in personal adjustment by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att.8) |
06/30/2017
| Implemented |
| 2380.181(e)(4) | Individual #1's 4/5/17 assessment and Individual #2's 4/20/17 assessment did not include their need for supervision. | The assessment must include the following information: The individual¿s need for supervision. | Regarding regulation 2380.181e4 the program specialist updated Individual #1s and #2s assessment by addendum (att. 6 (#1s) and 7 (#2s)) to include the current need for supervision. PS and Director were retrained on this regulation (att. 4). Director will review all assessments to ensure adequate inclusion of current need for supervision by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(5) | Individual #2's 4/20/17 assessment did not include their ability to self-administer medications. Individual #2's assessment only indicated he/she did not take medications at program at this time. | The assessment must include the following information: The individual¿s ability to self-administer medications. | Regarding regulation 2380.181e5 the program specialist updated individual #2s assessment by addendum (att 7) to include his ability to self-administer medication. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure adequate inclusion of the ability to self-administer medication by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (Att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(6) | Individual #1 and #2's assessments, 4/5/17 and 4/20/17 respectively, did not include their ability to safely use and avoid poisonous materials. | The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Regarding regulation 2380.181e6 the program specialist updated Individual #1 and #2¿s assessment by addendum (att. 6 and 7) to include his ability to safely use and avoid poisonous materials. PS and Director were retrained on this regulation (att. 4). Director will review all assessments to ensure adequate inclusion of ability to safely use and avoid poisonous materials by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1's 4/5/17 assessment did not include their progress over the last 365 days 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. | Regarding regulation 2380.181(e)(13)(ii) the program specialist updated Individual #1¿s assessment by addendum (att. 6) to include his progress over the last 365 days in motor and communication skills. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure progress noted in motor and communication skills by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1's 4/5/17 assessment did not include their progress over the last 365 days 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. | Regarding regulation 2380.181(e)(13)(iii) the program specialist updated Indivdual #1s assessment by addendum (att 6) to include his progress over the past 365 days in personal adjustment. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure progress noted in motor and communication skills by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1's 4/5/17 assessment did not include their progress over the last 365 days 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. | Regarding regulation 2380.181(e)(13)(iv) the program specialist updated Indivdual #1s assessment by addendum (att 6) to include his progress over the past 365 days in socialization. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure progress noted in socialization by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(13)(v) | Individual #1's 4/5/17 assessment did not include their progress over the last 365 days 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. | Regarding regulation 2380.181(e)(13)(v) the program specialist updated Indivdual #1s assessment by addendum (att 6) to include his progress over the past 365 days in recreation. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure progress noted in recreation by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 4/5/17 assessment did not include their progress over the last 365 days 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. | Regarding regulation 2380.181(e)(13)(vi) the program specialist updated Indivdual #1s assessment by addendum (att 6) to include his progress over the past 365 days in community-integration. PS and Director were retrained on this regulation (att 4). Director will review all assessments to ensure progress noted in recreation by 6/30/17. Going forward an updated assessment format will be utilized to better capture this information. (att. 8) |
06/30/2017
| Implemented |
| 2380.183(5) | Individual #1's Individual Support Plan (ISP) did not include a protocol to address his/her social, emotional and environmental needs. Individual #1 was prescribed medication for Depression and Adjustment Disorder. | The ISP, including annual updates and revisions under § 2380.186 (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. | Regarding regulation 2380.183(5) the program specialist updated individual #1¿s SEEN plan to better incorporate the specific behaviors addressed at Life Time. (Attachment #1.) PS requested SC update the ISP to reflect the changes (att. 2) All staff were trained on updated SEEN plan (Att.3) PS and Director were retrained on regulation and SEEN plan procedure in place. (att. 4) Director and PS will review all current SEEN plans by 6/30/17 to ensure SEEN plans are accurate and included in ISPs. Going forward PS will review and update all SEEN plans at annual ISP reviews to ensure accuracy and inclusion in the ISP. |
06/30/2017
| Implemented |
| 2380.183(7)(i) | Individual #1's Individual Support Plan (ISP) did not include an assessment of his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming. | Regarding regulation 2380.183 7i the program specialist (plan lead in this case) updated Individual #2¿s ISP to incorporate his potential to advance in vocational training. (attachment 5). PS and Director were retrained on this regulation. (att 4). Director and PS will review all ISP¿s to ensure inclusion of potential for advancement in vocational training by 6/30/17. Going forward PS will review each ISP at annual ISP review meeting to ensure potential to advance in vocational training is adequately included. |
06/30/2017
| Implemented |
| 2380.183(7)(ii) | Individual #1's Individual Support Plan (ISP) did not include an assessment of his/her potential to advance in community involvment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Community involvement. | . Regarding regulation 2380.183 7ii the program specialist (plan lead in this case) updated Individual #2¿s ISP to incorporate his potential to advance in community involvement. (att. 5) PS and Director were retrained on this regulation (att.4). Director and PS will review all ISP¿s to ensure inclusion of potential to advance in community involvement by 6/30/17. Going forward PS will review each ISP at annual ISP review meeting to ensure potential to advance in community involvement is adequately included. |
06/30/2017
| Implemented |
| 2380.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include an assessment of his/her potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Competitive community-integrated employment. | Regarding regulation 2380.183 7iii the program specialist (plan lead in this case) updated individual #2¿s ISP to incorporate his potential to advance in community-integrated employment (att. 5) PS and Director were retrained on this regulation (att. 4). Director and PS will review all ISP¿s to ensure inclusion of potential to advance in community-integrated employment by 6/30/17. Going forward PS will review each ISP at annual ISP review to ensure potential to advance in community-integrated employment is adequately included. |
06/30/2017
| Implemented |