| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | On 6/10/14 Individual #1's sister asked residential group home staff for $25 of Individual #1's money so she could put gas in her car to take Individual #1 to a medical appointment. Residential staff gave Individual #1's sister $25 without consulting Individual #1. Individual #1 paid his sister $300 per month for the past year to board a horse at her house but there was no rental agreement between Individual #1 and his sister until today, 2/19/15. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | An agreement between individual and his sister was developed on 4/23/2015 regarding horse boarding and additional gas expenses. Using Care tracker, training,and documentation will occur with each supervisor and the individual finance coordinator regarding individual finances policy update, following update to individual finances policy. |
| Implemented |
| 6400.46(i) | Staff #2 had First Aid/CPR training in March 2011 and not again until 6/25/13. Staff #3 had First Aid/CPR training in May 2011 and not again until 7/30/13. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Adminstrative assistant reviewed all employee records to verify compliance. Care Tracker will document that all team members have been trained to ensure regulatory compliance with First-Aid and CPR certification. A tracking system will be developed and maintained. |
| Implemented |
| 6400.103 | The written evacuation procedure did not contain the individuals¿ responsibility during an evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Evacuation procedures were updated on 5/11/2015 to include individual's responsibilty during an evacuation. As noted during inspection visit, evacuation procedures for all other programs are in compliance. Using care tracker documentation, each supervisor will be trained on elements of evacuation procedures, including: individual and staff responsibilites, means of transportation and emergency shelter location. Using care tracker documentation, each supervisor will verify that each site has evacuation procedures that include: Individual and staff responsibilites, means of transportation emergency shelter location. |
| Implemented |
| 6400.104 | The notification letters sent to the fire department for all the individuals living in the home were sent on 10/29/13. The fire letter for Individual #2 and Individual #3 stated they only needed physical assistance at night to evacuate the home. The fire drill logs for the home from 2/19/14 until 1/27/15 recorded 6 occurrences that Individuals #2 and #3 needed physical assistance during awake fire drills as well. The fire department notification letter was not kept current. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Fire notification letter was updated on 2/19/2015 to include accurate information regarding the needs of individuals for assistance. As noted during inspection visit, fire notification letters reflect the needs of individual in regards to fire evacuation assistance. Care tracker documentation will verify that each supervisor was trained on proper notification to the local fire department. Specifically, 1. in writing. 2. Address of the home. 3. The exact location of the bedrooms(diagram of the home) 4. The letter shall be current. |
| Implemented |
| 6400.112(h) | The fire drill held on 10/24/14 did not indicate whether all individuals went to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program coordinator of each program will verify that subsequent(since 2/20/2015) fire drills included information that verfies that each individual evacuated to the designated meeting place and monthly thereafter. Care tracker documentation will verify that all supervisors and program coordinators are trained on fire drill expectations and documentation particularly. 1. unannounced fire drill is held at least monthly. 2. fire drills shall be held at normal staffing conditions, 3. a written record shall be kept of the date, time, the amount of timeit took for evacuation, the exit route used, problems encountered and wether or not the fire alarm or smoke detector was opertative. 4. individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert within 2.5 minutes or within the period of time specified in writing within the past year by a fire safety expert. |
| Implemented |
| 6400.141(c)(10) | The communicable disease status was left blank on the physical for Individual #1 dated 8/21/14. The doctor did not note anywhere else on the physical that Individual #1 was free of communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Free of communicable diseases. All individual physical exam forms will be audited by program supervisor, to ensure regulatory compliance with communicable disease status. Supervisors were trained of the necessity to have all components of the individual physical form completed. Care tracker documentation will show that all supervisors have verfied that all individual physicals are completed, especially identifying if the individuals is free of communicable disease. |
| Implemented |
| 6400.151(a) | Staff #3 had a physical completed on 1/20/11. Staff #3 had not had a physical completed since then. Staff #3 was due for a physical by 1/20/13 and another one by 1/20/15. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | staff #3 was taken off shift coverage immediately on 2/20/2015. Team member returned to work on 2/25/2015 when complted empolyee physical including a TB test was obtained. All team member records were reviewed by the human resources department on 2/24/2015 to verify regulatory compliance. At that review, all TM records were updated to ensure regulatory compliance. A quartlery review of team member physcial exam dates will occur to ensure regulatory compliance. |
| Implemented |
| 6400.151(c)(2) | Staff #3 had a TB test completed on 1/26/11 and hasn¿t had one completed since then. Staff #3 was due for a TB by 1/26/13 and again on 1/26/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | staff #3 was taken off shift coverage immediately on 2/20/2015. Team members returned to work on 2/25/2015 when completed employee physcial including a TB test was obtained. All team members records were reviewed by the human resources department on 2/24/2015 to verify regulatory compliance. At that review, all Tm records were updated to ensure regulatory compliance. A quarterly review of team members physcial exam dates will occur to ensure regulatory compliance. |
| Implemented |
| 6400.151(c)(3) | The only physical for Staff #3 on file that was completed on 1/20/11 did not indicate whether Staff #3 was free of communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #3 was taken off shift coverage immediately on 2/20/2015. Team member returned to work on 2/25/2015 when completed employee physcial including a TB test was obtained and documentation to verify that employee is free from communicable diseases. All team members records were reviewed by the human resources department on 2/24/2015 to verify regulatory compliance. A quartlery review of team member physical exam dates will occur to ensure regulatory compliance. |
| Implemented |
| 6400.167(b) | The medication review for Individual #1 on 3/4/14 with his psychiatrist stated that he was to take Risperidone .5mg in the morning. There was a follow up letter on 3/5/14 from Individual #1's psychiatrist confirming that Risperidone was to be administered in the morning. Risperidone continued to be administered at night until Individual #1's next psychiatric appointment on 5/27/14. At the 5/27/14 appointment the psychiatrist prescribed Risperidone to be administered at night. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Clarification regarding medication admisitration time was obtained on 3/6/2015 and MAR was compared to prescribing order. Each supervisor will audit each medication adminsitration record to assure that it matches current physcian's orders. Care tracker documentation will verify that each supervisor is trained to ensure that prescription medications shall be administered according to the directions specified by a licensed physicain certified nurse practitioner or licensed phsycians assisstant. |
| Implemented |
| 6400.181(b) | Individual #1 broke his femer in the winter of 2014. Individual #1 completed rehabilitation at another facility and finally returned home on 1/30/15. It was determined by his physician and team prior to his return home that Individual #1 would need an increase in supervision level at his residential group home. The assessment for Individual #1 was not revised to show the change in increased need for supervision services at his residential group home. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | Assessment for individual 31 was updated 3/6/2015 to include relevent medical information related to an injury. All program specialists will be trained to initiate an updated individual assessment if there is a recommendation to revise a service or outcome in the ISp. An addendum template developed and implemented as a practice for use in requesting new services. An sdjustment to programming structure is being implemented to ensure compliance. an addendum template will be utilized as a practice for use in requesting new services. Training for program specialist team regarding this new practice will occur. |
| Implemented |
| 6400.181(e)(13)(ii) | The assessment for Individual #1 did not include progress and growth in the area of motor and communication. | 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. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in motor an communication skills. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in motor and communication skills. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in motor and communication skills. |
| Implemented |
| 6400.181(e)(13)(iii) | The assessment for Individual #1 did not include progress and growth in the area of 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. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in activities of residential living. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in activities of residential living. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in activities of residnetial living. |
| Implemented |
| 6400.181(e)(13)(iv) | The assessment for Individual #1 did not include progress and growth in the area of 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. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in personal adjustment. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in personal adjustment. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in personal adjustment. |
| Implemented |
| 6400.181(e)(13)(v) | The assessment for Individual #1 did not include progress and growth in the area of 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. | |
| Implemented |
| 6400.181(e)(13)(vi) | The assessment for Individual #1 did not include progress and growth in the area of 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. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in recreation. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in recreation. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in recreation. |
| Implemented |
| 6400.181(e)(13)(vii) | The assessment for Individual #1 did not include progress and growth in the area of 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.
| assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in fincancial independence. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in financial independence. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in financial independence. |
| Implemented |
| 6400.181(e)(13)(viii) | The assessment for Individual #1 did not include progress and growth in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in managing personal property. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in managing personal property. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in managing personal property. |
| Implemented |
| 6400.181(e)(13)(ix) | The assessment for Individual #1 did not include progress and growth in the area of 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. | assessment for individual #1 was updated on 3/6/2015, to include current information related to progress and growth in community-integration. All program specialists will be trained to include on individual assessments updated and current information related to progress and growth in community-integration. Each program specialist will verify that infividual assessments include updated and current information related to progress and growth in community-integration. |
| Implemented |
| 6400.183(3) | The Individual Support Plan (ISP) for Individual #1 did not have his current status in relation to his expected outcome. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | An isp update request was submitted to support coordinator on 2/16/2015. Program specialist will ensure that each subsequent 9form date of plan correction) ISP quarterly review acutatley reflecys the current status of each individual. |
| Implemented |
| 6400.186(c)(2) | The Individual Support Plan (ISP) reviews for Individual #1 on 2/20/14, 5/12/14, and 8/25/14 did not include a review of his behavior support plan for the quarter. Individual #1 was having behaviors that were recorded on monthly documentation notes but the ISP reviews stated he was not having behaviors. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | ISP quarterly review was updated to reflect an update of maladaptive behavior plan on 2/25/2015. Each subsequent (since 2/20/2015)ISP quarterly review will be reviewed to assure that it includes a summary of the behavior support plan and progress. |
| Implemented |