| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff B's previous physical was dated 11/6/2010. The most recent physical was dated 1/24/14. | 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. | A staff person's previous physical was dated 11/6/10. The most recent physical was dated 1/24/14. Effective 7/1/2014, Interact's Human Resources department implemented sending out to Program Supervisors a monthly 60 day Outlook report to ensure compliance to staff physical due date requirements. In this way, the due dates can be communicated with staff in advance and tracked in a pro-active manner so as to avoid any non-compliance. If someone is identified as not being able to meet his/her 2 year physical date, the staff person will be immediately removed from the schedule until the physical can be completed, and will not be able to return to work until it is completed and meets regulations as verified by the staff's supervisor and submitted to Human Resources department.
In addition, routine staff file audits will occur by Asst Director as assigned by Co-Directors to ensure compliance has been maintained.
|
07/01/2014
| Implemented |
| 6400.168(a) | Staff C has not had medication administration training but has administered medication. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff did not have current medication training documented in her file. As a result, this staff person was immediately pulled from passing medications until she could be retrained and re-tested which has occurred. In addition, Interact completed an inventory of all staff files to ensure every page of every medication administration certification packet was current and completed in entirety. Any staff that was identified as being out of compliance was pulled from medication passes and retrained and retested. The retraining/retesting process was concluded on 9/16/14. Spreadsheets were created to assist Practicum Observers in accurately maintaining/tracking certifications for their staff to ensure they remain current going forward. Routine staff file audits will occur by Asst Director as assigned by Co-Directors to ensure compliance has been maintained. This individual was terminated for unrelated reason; med training was not necessary |
07/11/2014
| Implemented |
| 6400.183(5) | Individual # 1 has a diagnosis of Adjustment Disorder and Schizophrenia but did not have a Social Emotional and Environmental Plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | A resident had a diagnosis of Adjustment Disorder and Schizophrenia but did not have a Social, emotional and Environmental Plan in place. A Social, Emotional and Environmental Plan has been re- implemented for this resident on 7/9/14 at which time the Supports Coordinator was also notified for the purpose of inputting information into her ISP. A copy of individual's ESP will be submitted as supporting documentation. All charts of residents who are on psychotropic medications were reviewed to ensure they have Behavior Plans or Social Emotional Plans in place as required. Additionally, all Program Managers were re-trained in 8/2014, and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, quarterly peer review/client chart audits will be completed by Program Mgrs as assigned by CHS Co-Directors to ensure compliance. Full client chart audits will also be completed at management level by Co-Directors, Asst Director, and Quality Assurance Specialist on a semi-annual basis as further assurance to licensing compliance.
See attachment #1
|
07/09/2014
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews of 11/8/13 and 2/7/14 did not include information regarding behavioral challenges.
| The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | A resident's ISP quarterly reviews of 11/8/13 and 2/7/14 did not include information regarding behavioral challenges. An addendum was added to each quarterly review by the Program Manager on 7/9/14 and shared with the Supports Coordinator to include information on behaviors to be included in her ISP. Additionally, all Program Managers were re-trained in 8/2014, and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance. Furthermore, quarterly peer review/client chart audits will be completed by Program Mgrs as assigned by CHS Co-Directors to ensure compliance. Full client chart audits will also be completed at management level by Co-Directors, Asst Director, and Quality Assurance Specialist on a semi-annual basis as further assurance to licensing compliance. See attachments #2, #3, and #4. |
07/09/2014
| Implemented |