| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(18) | An individual residing in the home has a contagious disease. The direct care staff were not trained on the health and safety needs relevant to the individual. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Staff who work at the site were re-trained on universal precautions and the specific disease of the resident (attachments #42 and 43). One staff who did not show to the training, despite frequent reminders and attempts to accommodate his schedule was removed from working at the site, due to his noncompliance in being trained as required. This non-compliant staff will be removed from the schedule until he gets the required training. A competency quiz was given at the end of the training to ensure that staff understood what precautions should be taken, as they pertain to the specific disease of the resident. Going forward, Interact will continue to require annual policy and procedure training for all CHS staff, and this training will include universal precautions and ISP training requirements. In addition, program manager and nurse at a site will be responsible for training on any specific health conditions that arise with individuals at a home. |
10/23/2015
| Implemented |
| 6400.62(a) | There was Gillette and Degree deodorant, which noted to contact poison control if ingested, in an unlocked cabinet upstaires and in Individual #1's bedroom. Individual #1 cannot handle poisons safely. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The deodorants were immediately removed from the upstairs and locked with other personal hygiene products. A lock was placed on the cabinet upstairs in Individual #1's bedroom, and all deodorants and any other poisons are now maintained in the locked cabinet (attachment #40). Memo was issued to all CHS re: keeping household poisons, including personal care items, locked, unless all individuals in the home can handle poisons safely (attachment #41). All program managers will visit their sites to ensure compliance of this regulation on a regular basis and submit documentation to CHS co-directors biweekly to document such on the CHS site review checklist. Additionally, the CHS Co-Directors, the Assistant CHS Director, and the Quality Assurance Assistant implemented a weekly alternating tour of each site to further ensure compliance to such. Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program manager and/or staff as needed. |
09/15/2015
| Implemented |
| 6400.64(a) | The blinds in the kitchen and bathroom were covered with dust. The toilet bowl in the upstairs bathroom had brown stain. | Clean and sanitary conditions shall be maintained in the home. | The blinds in the kitchen and bathroom were cleaned (attachments #35 and 36). Toilet bowl was cleaned and scrubbed (attachment #37). Program manager instituted a cleaning assignment list and will be maintained and reviewed (attachment #32). To ensure compliance, Interact will assure that clean and sanitary conditions are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
09/17/2015
| Implemented |
| 6400.64(e) | There was a trash can in the basement without a lid. | Trash receptacles over 18 inches high shall have lids. | The trashcan was immediately removed and replaced with a trashcan with a lid (attachment #39). All program managers will visit their sites to ensure compliance of this regulation on a regular basis and submit documentation to CHS co-directors biweekly to document such on the CHS site review checklist. Additionally, the CHS Co-Directors, the Assistant Director and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program manager and/or staff as needed. |
09/16/2015
| Implemented |
| 6400.67(a) | The microwave in the kitchen had a broken handle and the bottom was cracked. | Floors, walls, ceilings and other surfaces shall be in good repair. | The microwave was replaced (attachment #34). Interact will assure that clean and sanitary conditions as well as furniture and equipment shall be nonhazardous, clean, and sturdy and well maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to Co-Directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
09/24/2015
| Implemented |
| 6400.71 | The telephone in the sitting room, near Individual #2's bedroom, did not have emergency numbers posted nearby. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Emergency numbers of the nearest hospital, police department, fire department, ambulance and poison control center was posted on the telephone in the sitting room near Individual #2's bedroom (attachment #33). All program managers will visit their sites to ensure compliance on a regular basis and submit documentation to CHS co-directors biweekly to document such on the CHS site review checklist. Additionally, the CHS Co-Directors, the Assistant CHS Director, and the Quality Assurance Assistant implemented a weekly alternating tour of each site to further ensure compliance to such. Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program manager and/or staff as needed. |
09/16/2015
| Implemented |
| 6400.76(a) | There was lint in the dryer the size of a tennis ball. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The lint in the dryer was immediately removed (attachment # 30). All CHS staff received a memo re: the importance of checking dryer lint trap after each cycle (attachment #31). Program manager developed a cleaning schedule, and checking dryer lint trap after each cycle is on the cleaning schedule (attachment #32). To ensure compliance, Interact will assure that clean and sanitary conditions, as well as furniture and equipment shall be nonhazardous, clean, and sturdy and well maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist which will be submitted to co-directors biweekly. Additionally, the CHS co-directors, assistant director and quality assurance specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
09/17/2015
| Implemented |
| 6400.101 | The exit door in the basement did not open freely. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Maintenance immediately addressed the issue of the basement door not opening freely. The door was removed completely because it was not an exit door. It was a door leading to the bilko doors, so it was not needed (attachment #29). To ensure compliance, Interact will assure that clean and sanitary conditions, as well as unobstructed exits are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
09/16/2015
| Implemented |
| 6400.181(c) | Individual #3's assessment, dated 2/20/15, did not include the basis of the assessment. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including that the assessment shall be based on assessment instruments including interviews, progress notes and observations (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance with this regulation, program managers as assigned by CHS Co-Directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance |
10/12/2015
| Implemented |
| 6400.181(e)(6) | Individual #3's assessment, dated 2/20/15, did not include the individual's ability to safely use or avoid poisons. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including that the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance, program managers as assigned by CHS co-directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/12/2015
| Implemented |
| 6400.181(e)(7) | Individual #3's assessment, dated 2/20/15, did not include the individual's awareness of heat sources and the ability to move away 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. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including that the individual's knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance, program managers as assigned by CHS co-directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/12/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #3's assessment, dated 2/20/1,5 did not include progress and growth in the area 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 form has been updated and revised to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in managing personal property (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance, program managers as assigned by CHS co-directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/21/2015
| Implemented |
| 6400.181(e)(13)(ix) | Individual #3's assessment, dated 2/20/15, 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 form has been updated and revised to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in community integration (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance, program managers as assigned by CHS co-directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/12/2015
| Implemented |
| 6400.181(e)(14) | Individual #3's assessment, dated 2/20/15, did not include progress and growth in the area of water safety and ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in the individual's knowledge of water safety and ability to swim (attachment #27). Individual #3's assessment was updated 10/12/2015 to include the missing component (attachment #28). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, 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 with assessment requirements. Furthermore, to ensure compliance, program managers as assigned by CHS co-directors will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/12/2015
| Implemented |
| 6400.186(b) | The program specialist did not date the Individual Support Plan (ISP) reviews for the year for Individual #3. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Issue was addressed with program manager, and she was reminded of the importance of signing all documents she signs, via a memo (attachment #26). Moving forward, Interact has incorporated a checks and balance system along with a quality assurance spreadsheet in which program specialist can keep track of when quarterly's are due. This spreadsheet is shared with all program managers on a monthly basis to assure that quarterly summaries and other required client records are completed on a timely basis. Additionally, all program managers will be re-trained in 11/2015, 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 managers as assigned by CHS co-directors to ensure compliance. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi annual basis as further assurance to licensing compliance. |
09/23/2015
| Implemented |