| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(b) | The nursing room had poisonous items unlocked; Lysol cleaning spray, Clorox wipes, and Povidone Iodine Prep Solution. | Poisonous materials shall be stored in their original, labeled containers. | Cleaning supplies and iodine were removed on 4/13/18. Cleaning supplies and iodine will not be stored in this cabinet. The location will be added to the safety checklist and location will be checked on a regular basis. |
04/13/2018
| Implemented |
| 2380.84 | The annual fire safety inspection was late. It was completed 5/19/2016 and not again until 6/5/2017. | The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | The next annual fire safety inspection is scheduled for 5/24/18. This is within the required time frame.
The annual inspection date will be added to the Facility Maintenance PM schedule. The Property Manager will schedule the annual fire safety inspection within the required time frame. |
05/24/2018
| Implemented |
| 2380.113(a) | The CEO, staff #1, did not have a completed physical. He meets the requirements of the regulation. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The CEO completed a physical on 4/5/18the form was not on site. The form was sent with other supporting documentation. HR monitors a master list of employees that are required to get a physical every 2 years. Staff #1 will be added to the list. |
04/05/2018
| Implemented |
| 2380.113(c)(2) | The CEO, staff #1, did not have a TB test completed. He meets the requirements to have a physical examination completed. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant. | The CEO completed a TB test on 4/28/18. The form was sent with other supporting documentation. HR monitors a master list of employees that are required to get a TB test every 2 years. Staff #1 will be added to the list. |
04/28/2018
| Implemented |
| 2380.122(a) | Individual #3 is prescribed Acetaminophen 325mg tab take 2 tabs by mouth every 4 hours as needed for mild to moderate pain. The medication that is available at the day program states, Stock for Day Program Acetaminophen 325mg tab use as directed. | 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. | The medication that was not in the original container was removed on 4/16/18 and replaced with a bottle with the original label. All medications will have original labels. |
04/16/2018
| Implemented |
| 2380.155(a) | In classroom #7 the refrigerator and freezer was locked. No individuals that are provided services in that room are on a restrictive procedure plan. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures. | Locks were removed from refrigerator on 4-13-18. If a restrictive procedure becomes necessary in the future, a plan will be developed and presented to the Human Rights Committee for approval. |
04/13/2018
| Implemented |
| 2380.173(9) | Individual #1 current ISP states staff do not need to be with her during meal time. She can be in the bathroom with the door shut and staff will check on her every 5 minutes. Individual #1 Assessment 2/5/2018 states staff must feed her during meals and assist her in the bathroom. | Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program Specialist were retrained on the review of ISP and how to document requested changes in the quarterly review form. |
05/23/2018
| Implemented |
| 2380.181(e)(7) | Individual #1 Assessment 2/5/2018 and Individual #2 Assessment 3/8/2018 does not state their ability to sense and move away quickly from heat sources. | The assessment must include the following information: The individuals 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. | The assessment is updated to include the individuals ability to sense and move away from heat sources. |
05/22/2018
| Implemented |
| 2380.181(e)(10) | Individual #1 Assessment 2/5/2018 and Individual #2 Assessment 3/8/2018 did not include the lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The Program Specialists were retrained to complete the Life Time Medical history on the actual assessment form and not to attach a copy to the assessment document. |
05/23/2018
| Implemented |
| 2380.181(e)(12) | Individual #1 assessment 2/5/2018 and Individual #2 Assessment 3/8/2018 did not include Recommendations. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | The assessment is updated to include recommendations for specific area of training, vocational programming and competitive-integrated employment. |
05/22/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual #1 Assessment 2/5/2018 did not include progress and growth in the area of Health. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health. | The Program Specialist were retrained on the completion of the annual assessment form. The training included the expectation for specialist to explain the individuals progress and growth in each area of the assessment. |
05/23/2018
| Implemented |
| 2380.181(e)(13)(ii) | Individual #1 Assessment 2/5/2018 did not include progress and growth in the area of 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. | The Program Specialists were retrained on the completion of the annual assessment form. The training included the expectation for specialist to explain the individual¿s progress and growth in each area of the assessment. |
05/23/2018
| Implemented |
| 2380.181(e)(13)(iii) | Individual #1 Assessment 2/5/2018 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. | The Program Specialists were retrained on the completion of the annual assessment form. The training included the expectation for specialist to explain the individual¿s progress and growth in each area of the assessment. |
05/23/2018
| Implemented |
| 2380.181(e)(13)(iv) | Individual #1 Assessment 2/5/2018 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. | The Program Specialists were retrained on the completion of the annual assessment form. The training included the expectation for specialist to explain the individual¿s progress and growth in each area of the assessment. |
05/23/2018
| Implemented |
| 2380.181(e)(13)(v) | Individual #1 Assessment 2/5/2018 did not show 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. | The Program Specialists were retrained on the completion of the annual assessment form. The training included the expectation for specialist to explain the individual¿s progress and growth in each area of the assessment. |
05/23/2018
| Implemented |
| 2380.181(e)(14) | Individual #1 Assessment 2/5/2018 and Individual #2 Assessment 3/8/2018 did not include their ability to swim. | The assessment must include the following information: The individuals knowledge of water safety and ability to swim. | The Assessment is updated to include the individual¿s ability to swim. |
05/23/2018
| Implemented |
| 2380.186(c)(2) | Individual #2 protocols: Aspiration, Chopped Diet, Gait Belt, Seizure, and Wheelchair were not reviewed as part of her ISP reviews over the annual review year. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | The quarterly review form is updated to include review of protocols. |
05/22/2018
| Implemented |
| 2380.186(e) | Individual #1 and #2 Program Specialist did not notify the plan team members of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The quarterly review form was updated to include the following statement: Enclosed is a copy of the Quarterly Review of your current ISP. If you or any team member disagrees with any content of this document or does not want to receive this quarterly, please notify the Program Specialist in writing. If you have any questions, please feel free to call me at: 203-267-1500 Ext: XXX |
05/22/2018
| Implemented |