| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 7/1/17 Individual #1's own funds were used to purchase a bedbug cover for his/her bed costing $37.58 when this was an agency requirment due to an outbreak of bedbug within their facility. There was no documentation to indicate that Individual #1 agreed to purchase the item out of his/her own funds. | Individual funds and property shall be used for the individual's benefit. | Immediate: Individual #1¿s repayee was made aware of the 7/1/17 purchase of bed bug protectors on 7/26/17 and provided verification on 9/7/17 that he verbally provided consent on 7/26/17 of this purchase from Individual #1¿s personal funds, as the purchase allows for Individual funds and property to be used for the Individual¿s benefit.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that each Individual¿s funds and property are used for the Individual¿s benefit and that each Individual¿s Individual Support Plan includes team recommendations for the use of individual funds for purchases beyond routine personal needs expenses to ensure Individual and ISP Team financial consent.
Global Preventative: An Associate Director of Operations shall provide retraining to Program Coordinators on or before 9/18/17 regarding the requirement to review each Individual¿s current financial records during each calendar month¿s monitoring to ensure that each Individual¿s funds and property are used for the Individual¿s benefit. The Program Coordinator shall review each Individual¿s ISP on or before 10/31/17 to ensure familiarity with each Individual¿s financial safeguards. |
10/31/2017
| Implemented |
| 6400.67(a) | The basement sliding door/screen door would not slide the whole way open. The door only slid open approximately 1-2 feet. | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediate: The facility¿s downstairs exterior door was adjusted on 7/21/17 by a member of the Maintenance Team to ensure ease of access.
Global Immediate: Program Managers shall be instructed by a Program Coordinator on or before 8/22/17 to perform a physical site review to identify any floors, walls, ceilings and other surfaces that may need to be repaired at each physical site, with the expectation to communicate all repair needs to the Maintenance Team on or before 9/15/17.
Global Preventive: A Program Coordinator shall retrain Program Managers on or before 8/22/17 regarding the requirement to ensure that all floors, walls, ceilings and other surfaces are maintained in good repair, including the expectation that any needed repairs noted to surfaces are requested of the Maintenance Team immediately upon discovery. |
10/31/2017
| Implemented |
| 6400.68(b) | The water temperature in the home measured 122.1 degrees fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Immediate: On 7/21/17, Program Coordinator received confirmation that a member of the Maintenance Team adjusted the water temperature to ensure that it did not exceed 120 degrees Fahrenheit. Water temperature monitoring occurred on 7/27/17 and the Program Coordinator documented the kitchen sink water temperature as 108.1 degrees Fahrenheit.
Global Immediate: New thermometers shall be purchased for use by each Program Coordinator and distributed on or before 8/28/17 to ensure accurate and consistent readings within each facility. Each Program Coordinator shall compare readings from new and existing thermometers at each facility on or before 9/30/17, ensuring that any water temperature concerns are addressed immediately by communicating the need to adjust water temperature to the Maintenance Team. Any discrepancies noted between thermometers shall be addressed by replacing the inaccurate thermometer.
Global Preventative: Associate Director of Operations shall provide retraining to Program Coordinators on or before 8/28/17 regarding the requirement to check and record water temperatures during each calendar month¿s monitoring, alternating water sources each month. As applicable, Program Coordinators shall document any water temperature concerns noted and actions taken to address concerns, including the outcome, on the monthly monitoring form. |
10/31/2017
| Implemented |
| 6400.76(a) | Approximately a golf-ball sized piece of lint was located in the lint trap of the dryer.
| Furniture and equipment shall be nonhazardous, clean and sturdy. | Immediate: The lint ball discovered in the facility¿s dryer lint trap during licensing inspection on 7/14/17 was removed immediately upon discovery.
The facility¿s Team Members were retrained per a memo generated on 7/21/17 by a Program Coordinator regarding the requirement to remove lint from the dryer after each use. Additionally, the facility¿s Team Members were retrained by a Program Coordinator during a Team meeting on 7/27/17 to remove lint from the dryer trap after each use. A form was developed on 7/27/17 with the expectation of the Program Manager or designee to check the lint trap at least weekly and the Program Coordinator to check the lint trap at least monthly over the next 6 months, not ending sooner than 2/1/18, to ensure patterned compliance with ensuring furniture and equipment is nonhazardous, clean and sturdy.
Global Immediate: Program Managers shall receive retraining by a Program Coordinator on or before 8/22/17 regarding the expectation to ensure that lint is removed after use from each facility¿s dryer. Each Program Manager or designee shall retrain the Team Members within each program and document as such on or before 9/30/17 regarding this expectation.
Global Preventive: Associate Director of Operations shall provide retraining to Program Coordinators on or before 8/28/17 regarding the requirement to spot check each facility¿s lint trap during each calendar month and document findings and any actions taken to address concerns, as applicable, on the monthly monitoring form. |
10/31/2017
| Implemented |
| 6400.101 | Individuals #1 and #2 are not able to operate the latch style lock on the front and back gate egresses. Therefore, the front and back egresses were obstructed. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Immediate: Team Members were trained per a memo generated by a Program Coordinator on 7/21/17 regarding the requirement to leave the front and back gates open in order to ensure each Individual could evacuate the home without obstruction.
On 7/31/17, each latch to the front and back gate was removed to ensure ease of access to each Individual by the Maintenance Team.
Individuals within this facility have been trained by a Team Member on how to properly open the gates located at the front door and the home¿s rear exterior ramp on or before 8/11/17, each signing an affirmation of training.
Global Immediate: A Program Coordinator provided direction to Program Managers on or before 8/22/17 to assess each physical site with the expectation to communicate all repairs needed to the Maintenance Team on or before 9/15/17 regarding obstructions present at stairways, halls, doorways, passageways and exits from rooms and the buildings, as applicable.
Global Preventive: An Associate Director of Operations shall provide retraining on or before 8/28/17 to Program Coordinators regarding the requirement to assess each facility¿s interior and exterior physical site during each calendar month¿s monitoring to ensure that all stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed. Documentation of physical site assessments shall be recorded on the monthly monitoring form by the Program Coordinator and any follow-up actions required shall be documented, including outcome of such actions. |
10/31/2017
| Implemented |
| 6400.141(c)(7) | Individual #1's results from his/her 3/28/17 pap exam was not included on his/her 10/27/16 physical exam form or in his/her record. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Immediate: Individual #1¿s results were obtained by the medical provider and placed in the record for most recent gynecological exam that occurred on 7/14/17.
Global Immediate: A Program Coordinator shall retrain Program Managers on or before 8/22/17 regarding the expectation to obtain results verifying completion of gynecological examinations and/or other lab results within 10 days following each appointment where results are expected, documenting efforts to obtain results and date that results are received and filed.
Global Preventative: Nursing Consultants shall be retrained by an Associate Director of Operations and/or Nursing Services Coordinator on or before 9/18/17 regarding the requirement to review each Individual¿s record during each calendar month to verify that results and/or documented requests to obtain results within 10 days of an appointment where results are expected are maintained in the Individual¿s record. |
10/31/2017
| Implemented |
| 6400.142(a) | Individual #1 has a 3 month recall for dental appointments. He/She was seen on 4/5/16 and not again until 9/21/16. | 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. | Immediate: The Director of Operations retrained Program Coordinator on 7/14/17 regarding the expectation to ensure that each Individual receives a dental examination by a licensed dentist at least annually, or at more regular intervals as recommended by a licensed dentist.
The Program Coordinator confirmed upcoming scheduled dental examination appointment for Individual #1 on 8/31/17. Individual #1¿s next scheduled appointment is on 9/26/17, which will meet the requirement of an annual appointment.
A Program Coordinator shall provide retraining on or before 9/28/17 for each Team Member responsible for facilitating and conducting medical appointments (i.e. Program Manager, Medical Support Professional, or Advisor 3) regarding the requirement of requesting a follow up appointment at recommended intervals prior to ending a currently attended appointment. Documentation of retraining shall be provided to the Orientation/Training Administrator to be retained in each applicable Team Member¿s file.
Global Immediate: An Associate Director of Operations shall provide retraining on or before 9/18/17 to Program Coordinators regarding the requirement to confirm at each calendar month¿s monitoring visit that all recommended follow up appointments have been scheduled with the applicable medical providers within the appropriate time frames as per regulations and/or physician recommendations.
Global Preventative: Nursing Consultants shall review each program¿s medical appointment reminder form during each calendar month¿s medical monitoring to ensure that each recommended appointment interval is tracked per medical provider recommendations. An Associate Director of Operations shall institute this practice on or before 9/18/17 for all subsequent calendar months. |
10/31/2017
| Implemented |
| 6400.142(b) | Individual #1's dental appointment form from 1/11/16 indicated that his/her prescribed Beniva "increases possibility of osteoporosis." Individual #1 has continued to be prescribed and take Beniva since that 1/11/16 appointment. However the dental appointment forms from 4/5/16, 9/21/16, and 12/22/16 did not indicate that Beniva was a medication known to cause dental problems. | An individual who is using medication known to cause dental problems shall have a dental examination by a licensed dentist at intervals recommended in writing by the dentist. | Immediate: Individual #1 attended a dental appointment on 7/20/17 where a licensed dentist indicated implications of Boniva on oral health or hygiene on her Dental Progress Record, meeting the requirement to have a dental examination by a licensed dentist at intervals recommended in writing by the dentist.
Global Immediate: Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure dental examinations occur by a licensed dentist at intervals recommended in writing by the dentist, and that the licensed dentist addresses whether each Individual¿s current medications have implications for oral health or hygiene, which shall be documented accordingly on the Dental Progress Record at each dental appointment.
Global Preventative: Associate Director of Operations shall provide retraining to Program Coordinators on or before 9/18/17 regarding the requirement to review Dental Progress Notes during each calendar month¿s monitoring to ensure that: 1) a licensed dentist has provided documentation to verify that dental examinations by a licensed dentist have occurred at intervals recommended in writing by the dentist, on at least an annual basis and 2) a licensed dentist has provided documentation regarding potential implications of each Individual¿s current medications on oral health or hygiene at each dental appointment. |
10/31/2017
| Implemented |
| 6400.142(f) | Individual #1's dental hygiene plan indicated that he/she was to use mouthwash once per day. However his/her dental appointment on 9/21/16 indicated that he/she was to use mouthwash twice per day. This change was not updated on his/her dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Immediate: Individual #1 attended a dental appointment on 7/20/17 and received updated documented recommendations from a licensed dentist, including advisement to follow Individual #1¿s dental protocol last updated on 9/28/16.
Program Coordinator provided the most current dental recommendations to the Program Specialist on or before 8/31/17 and the Program Specialist provided the most updated dental protocol recommendations to the Supports Coordinator on 8/31/17.
The Program Coordinator confirmed on 8/31/17 that the dental hygiene plan and dental appointment record for Individual #1 consistently reflect Individual #1¿s current dental hygiene recommendations provided by a licensed dentist at her 7/20/17 dental appointment.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to maintain current dental hygiene plans per licensed dentist recommendations at all times in each Individual¿s record, unless the Individual¿s ISP Team has documented in writing that the Individual has achieved dental hygiene independence.
Global Preventative: During each calendar month¿s monthly medical monitoring, Nursing Consultants shall review each Individual¿s dental recommendations on their most current Dental Progress Note and compare to their most updated dental hygiene plan to ensure consistency throughout documentation. An Associate Director of Operations and/or the Nursing Services Coordinator shall retrain Nursing Consultants regarding this requirement on or before 9/18/17. |
10/31/2017
| Implemented |
| 6400.144 | REPEAT from 6/20/16 renewal inspection: Individual #1's diabetic protocol indicated " if he/she has blood glucose readings of greater than 350, call his/her dr. If blood sugar is greater than 200, at any time, recheck in one hour. If it has not gone down, call staff and oncall. Encourage Individual #1 to drink allowed water, walk, or do some type of exercise during that hour." On July 8th, 5th, 4th, 2nd, 1st, and June 28th, 22nd, 21st, 18th, 17th, 12th, staff recorded Individual #1's blood sugar was over 200. On every occasion, Individual #1's blood sugar level was not rechecked again in one hour. On July 8th, 4th, and June 21st, his/her blood sugar was over 350 and his/her doctor was not notified. Individual #1 had a new order to "test his/her blood sugar twice a day for one week starting 6/27/17. Then decrease testing to twice a week." His/Her blood sugar was only tested once a day on 6/29/17 and it was tested twice a day for 8 days. On 6/17/17 Individual #1's physician ordered "Glimepiride 1mg by mouth now. Check blood sugar in 4 hours and if its above 300 repeat the medication again. Blood sugar is to be checked in the morning and if its above 300 give 2 tablets in the morning on Sunday." Individual #1's blood sugar was not checked 4 hours after the administration of Glimepiride or the next morning. | 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.
| Immediate: A Nursing Consultant faxed a request to Individual #1¿s Endocrinologist on 7/24/17 regarding verification of current glucose testing orders, medication administration clarification related to blood sugar parameters, and a review/approval of Individual #1¿s current Diabetic Protocol. Additionally, the fax contained glucose testing results from 7/1/17 to 7/5/17, as well as testing results from various dates between 7/7/17 and 7/24/17 for the Endocrinologist¿s review and input. The Endocrinologist responded via fax on 7/26/17 with recommendation for one minor change to the Diabetic Protocol for Individual #1. The Endocrinologist also indicated parameters to follow in regards to treatment for high blood sugar readings and approved all other documents as written on 7/26/17.
The Program Coordinator made the appropriate changes to the Individual¿s record on 7/31/17 in response to the fax received from Individual #1¿s Endocrinologist on 7/26/17. Program Coordinator placed the updated Diabetic Protocol in circulation for Team Members to review and acknowledge on 7/31/17.
Note: Time lapse between date received and date implemented was discovered by Program Coordinator and Director of Operations on the evening of 9/6/17 and was addressed by the Program Coordinator with the Team Members at the facility on 9/7/17.
Individual #1¿s current blood sugar orders were transcribed onto the Medication Log on 7/24/17 by the Program Coordinator to eliminate multiple locations of documentation related to blood sugar protocols and Diabetes management on behalf of Individual #1.
Team Members received retraining on 7/24/17 regarding the discontinuation of separate blood sugar tracking forms and institution of streamlined documentation on the Medication Log on an ongoing basis.
A Nursing Consultant provided retraining for Team Members on glucometer use on 7/20/17. Nursing Consultant documented confirmation that Team Members demonstrated proper use of the glucometer during retraining on 7/20/17.
A new glucometer was obtained on or before 8/3/17 to ensure accurate readings and memory storage of data to be compared at least weekly with blood sugar tracking on behalf of Individual #1. Although the glucometer device is of the same make and model of the previous device used, an instruction guide was updated on 8/7/17 by the Program Coordinator for Team Members to reference regarding the glucometer features and instructions on verifying that the correct date and time is set on the device.
Per recommendation from ODP Inspector, an accountability measure was instituted on 7/24/17 by the Program Coordinator whereas the Program Manager, Nursing Consultant, Program Coordinator, or other trained professional shall verify blood sugar readings are accurately recorded at least weekly by comparing the blood sugar tracking log and glucometer memory data. Any discrepancies noted at the time of verification (as applicable) shall be recorded on the Medication Log notation page and communicated to the reviewer¿s immediate supervisor for further review and determination of appropriate follow-up actions. Additionally, any discrepancies noted (as applicable) shall be discussed by the Program Coordinator, Team Member responsible for the period of time in question, and a Nursing Consultant within 24-28 hours upon discovery to explore the origin of discrepancy and formulate a plan of correction.
A referral was made to the South Central Health Care Quality Unit by the Program Coordinator on 9/6/17 to request Team Member training in regards to signs and symptoms of high and/or low blood sugar, prevention of complications related to Diabetes, and how to manage fluid restrictions in conjunction with Diabetes management in order to enhance medical oversight and support on behalf of Individual #1.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that all health se |
10/31/2017
| Implemented |
| 6400.162(a) | Individual #1's blood sugar test strips contained three different medication labels for how often to test his/her blood sugar. The 3 different labels indicated "test twiced per day," "test once per day," and " once per week and as needed." Individual #1 had a doctor order in his/her record to test his/her blood sugar twice per week on 6/27/17. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Immediate: On behalf of Individual #1, each blood sugar test strip and lancet prescription label was updated on 7/25/17 by the pharmacy based on updated endocrinology orders received by the pharmacy (electronically from the Endocrinologist) on 7/25/17. The Program Coordinator updated Individual #1¿s Medication Log on 7/25/17 to ensure consistency with prescription labels.
Global Immediate: Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that all prescription labels match current orders on behalf of each Individual, including accurate corresponding Medication Logs. Each Program Manager or designee shall confirm each Individual¿s orders, prescription labels, and Medication Logs are accurate, including all medications available in stock, on or before 9/30/17. This verification shall be documented by those completing the review.
Global Preventative: Associate Director of Operations and/or Nursing Services Coordinator shall provide retraining to Program Coordinators and Nursing Consultant Team on or before 9/18/17 regarding the requirement to routinely monitor prescription labels and Medication Logs in comparison to current physician¿s orders to ensure each Individual¿s health and safety in relation to medication administration. |
10/31/2017
| Implemented |
| 6400.164(a) | REPEAT from 6/20/16 renewal inspection: Individual #1 was prescribed Polyethylene glycol. The medication label did not match the medication administration record (mar). The mar did not include " continue to give daily until significant BM (bowel movement) occurs. If no significant BM in 5 days, contact PCP." | 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. | Immediate: Individual #1¿s Medication Log was corrected on 7/21/17 by a facility Medication Trainer to include the entire contents of the prescribed medication pharmacy label on the corresponding Medication Log box.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that each Individual¿s Medication Log is transcribed directly from the corresponding medication label and that the Medication Log is kept current at all times.
Global Preventative: Associate Director of Operations and/or Nursing Services Coordinator shall provide retraining to Program Coordinators and Nursing Consultant Team on or before 9/18/17 regarding the requirement to routinely monitor prescription labels and Medication Logs in comparison to current physician¿s orders to ensure each Individual¿s health and safety in relation to medication administration, as well as to maintain accurate documentation of each administration. |
10/31/2017
| Implemented |
| 6400.167(b) | Individual #1 was prescribed Metformin 500mg take one tablet by mouth daily with breakfast on 6/27/17 according to a doctor's order. Individual #1 was administered Metformin starting 6/22/17, before it was ordered, according to the medication administration record (mar). On the same 6/27/17 physician's order, Individual #1 was prescribed a second Glimepirirde 5mg tablet in the evening. According to the mar, this medication was never administered. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Immediate: Documentation was obtained from the pharmacy on 7/25/17 by the Program Coordinator to verify Individual #1¿s prescribed medication was electronically ordered to be restarted on 6/21/17. Additionally, a fax received from the Endocrinologist on 7/26/17 verified the electronic order that was sent to the pharmacy on 6/21/17. This documentation verifies that the medication was received and administered on the proper date as per physician¿s orders and administered the following morning, 6/22/17, as documented on Individual #1¿s Medication Log. At an Endocrinologist appointment on 6/27/17, the Endocrinologist again documented the current order as it was written and sent electronically to the pharmacy on 6/21/17. All documentation as mentioned is currently maintained in Individual #1¿s record.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that each Individual¿s prescription medications are administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician¿s assistant and that all orders are maintained in each Individual¿s record.
Global Preventative: An Associate Director of Operations and/or the Nursing Services Coordinator shall provide retraining to Program Coordinators and Nursing Consultant Team on or before 9/18/17 regarding the requirement to monitor each Individual¿s record during each calendar month¿s monitoring to ensure that all current and previous physicians¿ orders are maintained on file. |
10/31/2017
| Implemented |
| 6400.181(e)(7) | Individual #1's 11/10/16 assessment did not include his/her ability to sense and move away quickly from heat sources. | The assessment must include the following information: 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. | Immediate: The Program Specialist updated the Assessment for Individual #1 on or before 7/21/17 to include the Individual¿s ability to sense and move away from heat sources.
Global Immediate: The Specialist Coordinator shall provide retraining to Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s ability to sense and move away quickly from heat sources within their annual Assessment, including updates as necessary.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s ISP Team to ensure that the Individual¿s ability to sense and move quickly away from heat sources has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 11/10/16 assessment did not include his/her progress and current level 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. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 11/10/16 assessment did not include his/her progress and current level in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's 11/10/16 assessment did not include his/her progress and current level 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. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's 11/10/16 assessment did not include his/her progress and current level 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. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 11/10/16 assessment did not include his/her progress and current level 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. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 11/10/16 assessment did not include his/her progress and current level in financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's 11/10/16 assessment did not include his/her progress and current level 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. | Immediate: The Program Specialist updated Individual #1¿s Assessment on 8/30/17 by generating an addendum to address Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration. This addendum was mailed to Individual #1¿s ISP team on 8/30/17.
Global Immediate: The Specialist Coordinator shall provide and document retraining for Program Specialists on or before 9/18/17 regarding the requirement to include each Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration within each Individual¿s updated Assessment.
Global Preventative: Beginning on or before 9/18/17, Specialist Coordinator or designee shall review each Individual¿s updated Assessment prior to dissemination to the Individual¿s team to ensure that the Individual¿s progress over the last 365 days and current level in the following areas: motor and communication skills, activities of residential living, socialization, recreation, financial independence, and community integration has been assessed and documented within the Assessment. Documentation of each review shall be verified via email or other form of documentation. |
10/31/2017
| Implemented |
| 6400.183(6)(i) | Individual #1's Individual Support Plan (ISP) did not include a protocol to eliminate the use of restrictive procedures or an assessment to determine the underlying causes or antecedents of the behavior. Individual #1's ISP indicated he/she did not have a restrictive procedure plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. | Immediate: The Program Specialist shall make a written request to the Supports Coordinator to update Individual #1¿s ISP on or before 9/18/17 to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures, as provided by the Program Specialist and/or Behavior Support Consultant.
Global Immediate: The Program Specialist Team shall review each Individual Support Plan on or before 10/15/17 to ensure that where applicable, each includes a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures. Updates to Individual¿s Individual Support Plans shall be requested by the Program Specialist as necessary and documented in the Individual¿s record as applicable.
Global Preventive: An Associate Director of Operations shall provide retraining to Behavior Support Consultants and Program Specialists on or before 10/15/17 regarding the requirement to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures within each Individual¿s restrictive procedure plan. The restrictive procedure plan shall then be provided to the Individual¿s Supports Coordinator by the designated Program Specialist for inclusion in the Individual¿s ISP as it is updated on an ongoing basis. |
10/31/2017
| Implemented |
| 6400.183(6)(ii) | Individual #1's Individual Support Plan (ISP) did not include a protocol for addressing the underlying causes or antecedents of the behavior. Individual #1's ISP indicated he/she did not have a restrictive procedure plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | Immediate: The Program Specialist shall make a written request to the Supports Coordinator to update Individual #1¿s ISP on or before 9/18/17 to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures, as provided by the Program Specialist and/or Behavior Support Consultant.
Global Immediate: The Program Specialist Team shall review each Individual Support Plan on or before 10/15/17 to ensure that where applicable, each includes a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures. Updates to Individual¿s Individual Support Plans shall be requested by the Program Specialist as necessary and documented in the Individual¿s record as applicable.
Global Preventive: An Associate Director of Operations shall provide retraining to Behavior Support Consultants and Program Specialists on or before 10/15/17 regarding the requirement to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures within each Individual¿s restrictive procedure plan. The restrictive procedure plan shall then be provided to the Individual¿s Supports Coordinator by the designated Program Specialist for inclusion in the Individual¿s ISP as it is updated on an ongoing basis. |
10/31/2017
| Implemented |
| 6400.183(6)(iii) | Individual #1's Individual Support Plan (ISP) did not include the method and timeline for eliminating the use of restrictive procedures. Individual #1's ISP indicated he/she did not have a restrictive procedure plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | Immediate: The Program Specialist shall make a written request to the Supports Coordinator to update Individual #1¿s ISP on or before 9/18/17 to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures, as provided by the Program Specialist and/or Behavior Support Consultant.
Global Immediate: The Program Specialist Team shall review each Individual Support Plan on or before 10/15/17 to ensure that where applicable, each includes a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures. Updates to Individual¿s Individual Support Plans shall be requested by the Program Specialist as necessary and documented in the Individual¿s record as applicable.
Global Preventive: An Associate Director of Operations shall provide retraining to Behavior Support Consultants and Program Specialists on or before 10/15/17 regarding the requirement to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures within each Individual¿s restrictive procedure plan. The restrictive procedure plan shall then be provided to the Individual¿s Supports Coordinator by the designated Program Specialist for inclusion in the Individual¿s ISP as it is updated on an ongoing basis. |
10/31/2017
| Implemented |
| 6400.183(6)(iv) | Individual #1's Individual Support Plan (ISP) did not include a protocol for intervention or redirection without utilizing restrictive procedures. Individual #1's ISP indicated he/she did not have a restrictive procedure plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. | Immediate: The Program Specialist shall make a written request to the Supports Coordinator to update Individual #1¿s ISP on or before 9/18/17 to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures, as provided by the Program Specialist and/or Behavior Support Consultant.
Global Immediate: The Program Specialist Team shall review each Individual Support Plan on or before 10/15/17 to ensure that where applicable, each includes a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures. Updates to Individual¿s Individual Support Plans shall be requested by the Program Specialist as necessary and documented in the Individual¿s record as applicable.
Global Preventive: An Associate Director of Operations shall provide retraining to Behavior Support Consultants and Program Specialists on or before 10/15/17 regarding the requirement to include a protocol to eliminate the use of restrictive procedures, an assessment to determine the underlying causes or antecedents of the behavior, the method and timeline for eliminating the use of restrictive procedures, and a protocol for intervention or redirection without utilizing restrictive procedures within each Individual¿s restrictive procedure plan. The restrictive procedure plan shall then be provided to the Individual¿s Supports Coordinator by the designated Program Specialist for inclusion in the Individual¿s ISP as it is updated on an ongoing basis. |
10/31/2017
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) and 11/10/16 assessment indicated that he/she required checks every 1-2 hours at night and every 30 minutes during the day if he/she is in his/her bedroom alone. The agency indicated this is not always being done and there was no documentation to track that the checks were done. | The ISP shall be implemented as written. | Immediate: A tracking mechanism was instituted by the Specialist Coordinator on or before 9/6/17 to record supervision checks on behalf of Individual #1 as written in the Individual¿s ISP and Assessment.
Global Immediate: Specialist Coordinator shall provide direction and oversight to Program Specialist Team to verify that a tracking mechanism is utilized to consistently record each Individual¿s supervision level checks on or prior to 9/18/17.
Global Preventative: The Specialist Coordinator shall provide retraining to Program Specialists on or before 9/18/17 regarding the requirement to ensure that each Individual¿s supervision level as per their Assessment is kept current within their record on an ongoing basis, including tracking mechanisms to verify supervision levels are adhered to. |
10/31/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews did not review his/her restrictive procedure plan, supervision checks, or and of his/her protocols; bowel, 48 oz fluid restriction, swallowing, fall, foot, diabetic and dental protocols. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Immediate: An Associate Director of Operations provided retraining to the Specialist Coordinator on or before 7/21/17 regarding the requirement to include a review of each section of the ISP specific to the residential home in each Individual¿s ISP Review, including restrictive procedure plan, supervision checks, and/or protocols, as applicable.
Individual #1¿s updated ISP Review will be completed by the Program Specialist on or before 9/28/17 and shall include information pertaining to Individual #1¿s restrictive procedure plan, supervision checks, and protocols.
Global Immediate: The Specialist Coordinator shall provide retraining to the Program Specialist Team on or before 9/18/17 regarding the requirement to include a review of each section of the ISP specific to the residential home in each Individual¿s ISP Review, including restrictive procedure plan, supervision checks, and/or protocols, as applicable.
A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that all protocols, restrictive procedure plans, supervision needs, and other ISP related documents are kept current and accessible to the Program Specialist for inclusion in each ISP Review.
Global Preventative: The Specialist Coordinator or designee shall review each Individual¿s ISP Reviews for a period of 90 days, beginning 10/1/17 and ending no sooner than 1/1/18, to ensure that all ISP information has been adequately reviewed and included in each ISP Review. The Specialist Coordinator shall document each review via email or alternate written documentation to verify completion, including recommendations for ISP Review revisions as applicable. |
10/31/2017
| Implemented |
| 6400.195(e)(5) | REPEAT from 6/20/16 renewal inspection: Individual #1's restrictive procedure plan did not include a target date for achieving the outcome. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| Immediate: Individual #1¿s restrictive procedure plan tracking template related to physician ordered fluids restriction was updated on 7/24/17 by the Program Coordinator to include a target date for achieving the outcome.
Global Immediate: An Associate Director of Operations shall provide retraining to Program Coordinators, the Nursing Services Coordinator, Nursing Consultants, Behavior Support Consultants, and Restrictive Procedures Committee Chairperson(s) on or before 9/18/17 regarding the requirement to include a target date for achieving each outcome at each review period.
Global Preventative: Restrictive Procedures Committee Chairperson(s) shall train and update the signature forms used by committee members on or before 10/18/17 to ensure that the team reviews and verifies that a target date is included in the restrictive procedure plan for each Individual for the designated review period prior to approving the plan for the next review period. |
10/31/2017
| Implemented |
| 6400.195(e)(8) | Individual #1's restrictive procedure plan did not include the name of the staff responsible for monitoring and documenting progress with the plan. | The restrictive procedure plan shall include: The name of the staff person responsible for monitoring and documenting progress with the plan.
| Immediate: Individual #1¿s restrictive procedure plan related to physician ordered fluids restriction shall be updated on or before 9/15/17 by the Program Coordinator and/or Program Manager to include staff person(s) responsible for monitoring and documenting progress with the plan.
Global Immediate: An Associate Director of Operations shall provide retraining to Program Coordinators, the Nursing Services Coordinator, Nursing Consultants, Behavior Support Consultants, and Restrictive Procedures Committee Chairperson(s) on or before 9/18/17 regarding the requirement to include the name of the staff person responsible for monitoring and documenting progress with the plan at each review period.
Global Preventative: Restrictive Procedures Committee Chairperson(s) shall train and update the signature forms used by committee members on or before 10/18/17 to ensure that the team reviews and verifies that the staff person responsible for monitoring and documenting progress with the plan is included in the restrictive procedure plan for each Individual for the designated review period prior to approving the plan for the next review period. |
10/31/2017
| Implemented |
| 6400.195(f) | Individual #1's restrictive procedure plan indicated that he/she was to be restricted to 48 ounces of fluid daily. However on multiple occasions, staff documented they measured and administered 50 ounces of fluid per day because the fluid chart indicated 50 ounces was to be administered that day. Some examples of the days where 50 ounces of fluid was administered per day or where the amount of fluid administered was not documented was 7/13/17, 6/19/17, 6/15/17, 6/9/17, and 5/25/17. | The restrictive procedure plan shall be implemented as written.
| Immediate: Individual #1¿s restrictive procedure plan tracking template related to a physician¿s ordered fluids restriction was updated on 7/24/17 by the Program Coordinator to ensure proper tallying of daily fluids not to exceed 48 ounces per day. All other tracking templates were removed from circulation on 7/24/17 by the Program Coordinator to ensure avoid use of improperly tallying templates.
Global Immediate: Program Managers or designees shall receive instruction by an Associate Director of Operations on or before 9/18/17 to ensure that all records on behalf of Individuals currently monitored per physician¿s orders to ensure restriction of fluids contain tracking forms to properly tally prescribed daily ounces of fluid intake.
Global Preventative: An Associate Director of Operations and/or the Nursing Services Coordinator shall provide retraining to Program Coordinators and Nursing Consultant Team on or before 9/18/17 regarding the requirement to monitor each Individual¿s record during each calendar month¿s monitoring to ensure that tracking forms are utilized to properly and adequately verify adherence to all physician¿s orders on file. The Program Coordinator and/or Nursing Consultant shall also verify during each calendar month that each restrictive procedure plan is implemented as written. |
10/31/2017
| Implemented |
| 6400.206 | Individual #1's restrictive procedure plan was never sent to his/her day service facility. | The individual's day service facility shall be sent copies of the restrictive procedure plan and revisions of the plan. Documentation of transmittal of the restrictive procedure plan shall be kept.
| Immediate: Individual #1¿s updated protocols, including restrictive procedure plan, was emailed to and received by day service facility on 8/8/17, as provided by the Program Coordinator.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that each Individual¿s day service facility, as applicable, is sent copies of the restrictive procedure plan and revisions of the plan, with documentation maintained in each Individual¿s file to verify transmittal of the plan.
Global Preventative: An Associate Director of Operations shall provide retraining to Program Coordinators on or before 9/18/17 regarding the requirement to monitor each Individual¿s record during each calendar month¿s monitoring to ensure that transmittal of restrictive procedure plan updates on behalf of each Individual, where applicable, is documented and maintained in the Individual¿s record. |
10/31/2017
| Implemented |
| 6400.212(b) | There were a few entries on Individual #1's dental records that did not include a date the entry and/or change was made on the record. Individual #1 had a dental appointment record from 1/11/16 in which the 16 was crossed off and changed to 17 by the house manager. Individual #1 never had a dental appointment on 1/11/17. Individual #1 also had a dental form dated 3/27/16 in which the 16 was crossed out and 17 was recorded. | Entries in an individual's record shall be legible, dated and signed by the person making the entry. | Immediate: Individual #1¿s dental records were updated on 7/14/17 to accurately portray the date of each verified dental examination per a fax received from licensed dentist on 7/14/17.
The Program Coordinator responsible for incorrect changes made to Individual #1¿s dental record was retrained by the Director of Operations on 7/14/17 regarding the requirement to verify all information prior to making changes to documents within all records, including the requirement to document required changes on a stand-alone document in lieu of altering original documentation.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that entries in an Individual¿s record are legible, dated and signed by the person making the entry.
Global Preventative: Program Coordinators shall review Individual¿s records during each calendar month¿s monitoring and verify that all entries in an Individual¿s record are legible, dated and signed by the person making the entry. Concerns noted with adherence to these expectations shall be addressed and documented at the time of discovery. |
10/31/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record information indicated ¿n/a¿ in the identifying marks field of his/her identification sheet. However according to staff, Individual #1 had surgical scars on his/her body that were identifying marks. Individual #1's religious affiliation was not included in his/her record. His/Her record only listed the name of the church he/she attend but did not include the affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Immediate: The Program Coordinator updated Individual #1¿s record to include specific identifying marks and religious affiliation information on 7/14/17.
Global Immediate: Program Managers have been instructed by a Program Coordinator on or before 8/22/17 to review the Individual Information sheet on behalf of each Individual by 9/30/17, making necessary updates as applicable.
Global Preventative: Program Coordinators shall be retrained by an Associate Director of Operations on or before 8/28/17 to review Individual Information sheets during each calendar month¿s monitoring to ensure that all required information is included as per this regulation. |
10/31/2017
| Implemented |
| 6400.213(11) | Individual #1's Individual Support Plan (ISP) indicated that his/her diet was "pureed food or mechanical soft diet," also " limit consentrated sweet, carbs, and minimum protein snacks. food pureed or cut into very small pieces and any meat he/she consumes must be extremely tender. 48 ounces per day fluid restriction." His/Her 10/27/16 physical examination form indicated that his/her diet was "48 ounces of fluid per day restriction, limit concentrated sweets, mechanical soft diet, cut up meats and puree non-soft foods." The two documents do not portray the same dietary information. His/Her ISP indicated that he/she required "line of sight and arm's reach supervision in the community" however his/her fall prevention plan indicated he/she only required line of sight supervision within the community. Individual #1 is a fall risk and requires arm's length supervision. His/Her ISP indicates that he/she needs assistance with hygiene after a bowel movement, however his/her bowel protocol indicated "if Individual #1 has more than 2 loose BM's in one day, you may hold -omit-the colace which he/she gets daily. Put an O in square and document on Notation page -omitted colace per doctor order due to X amt of loose BM's today." This standing order has since been discontinued and taken off of the protocol in his/her daily record book, but not been changed in his/her main file record. Individual #1's ISP indicated his/her diabetic protocol is current and up to date. His/Her diabetic protocol indicated to check his/her blood sugar once a week and as needed. However the diabetic protocol kept in his/her medical book at the house indicated that his/her blood sugar should be checked two times per week. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Immediate: Individual #1¿s Diabetic Protocol was updated by the facility¿s nurse on 7/24/17 and faxed to her Endocrinologist for review and approval which was subsequently received with further recommendations via fax on 7/26/17.
Individual #1¿s Diet Precautions/Protocol was updated on 8/3/17 by facility¿s Nursing Consultant to include all diet recommendations identified on her annual physical examination.
The Fall Prevention Protocol for Individual #1 was updated to include the requirement of arm¿s length supervision within the community on 7/13/17 by the Program Coordinator.
Individual #1¿s Bowel Protocol was updated by the facility¿s nurse on 8/11/17 to remove orders that have been previously discontinued by Individual #1¿s Primary Care Physician.
The Program Coordinator confirmed on 8/31/17 that all corresponding paperwork regarding Individual #1¿s protocols, including her physical examination form and ISP, accurately portray her current needs and physician recommendations.
Each protocol was provided to the Program Specialist on or before 8/31/17 and the Program Specialist provided all updated protocols to the Supports Coordinator on 8/31/17.
Global Immediate: A Program Coordinator shall provide retraining to Program Managers on or before 9/26/17 regarding the requirement to ensure that all physician recommendations are accurately recorded throughout each Individual¿s record and shall remain updated at all times. Additionally, each Program Manager shall be retrained by a Program Coordinator on or before 9/26/17 of the requirement to ensure that all Team Members have been trained regarding Individual¿s current protocols and support needs during orientation to the program and as changes occur on an ongoing basis to ensure adherence with all protocols and support needs.
Global Preventative: The Associate Director of Operations shall provide retraining to Program Coordinators on or before 9/18/17 regarding the requirement to review each Individual¿s physical examination form and medical recommendations, including all supporting documentation available to Team Members, during each calendar month¿s monitoring to ensure that each Individual¿s record accurately and consistently reflects physician recommendations and current support needs. |
10/31/2017
| Implemented |