| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temprature in the bathroom was 127 degrees when tested. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Why is the regulation important?
This regulation is important because it prevents individuals from getting burned.
How was the regulation violated?
The water temperature was 128 degrees F in the shower at one of the houses.
What caused the violation?
When staff used their thermometer, the temperature read 120 degrees F. However, when the licenser used her thermometer, the temperature read 128 degrees F.
What can be done right away to fix the violation?
The temperature in the shower was turned down immediately.
What can be done to prevent future violations?
On 2/22/16, the monthly Safety and Maintenance form was updated to say that water should not exceed 110 degrees F. The water temperature will be checked monthly using this form. (Attachment #2 Safety and Maintenance Check)
Who will be responsible for preventing future violations?
Program Support Managers will assign RPWs to check the water temperature each month. |
02/22/2016
| Implemented |
| 6400.142(f) | As per assessment dated 4/5/15, Individual #1 has not attained dental hygiene independence and there was no dental hygiene plan in place for the individual. | 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. | Why is the regulation important?
To ensure proper dental care is maintained.
How was the regulation violated?
As per assessment dated 4/5/15, Individual #1 has not attained dental hygiene independence and there was no dental hygiene plan in place for the individual.
What caused the violation?
The person completing the assessment missed that, since the individual requires staff intervention to ensure he brushes his teeth, a plan needed to be put in place to address this need.
What can be done right away to fix the violation?
Typically a plan would have been but in place and an addendum made to the ISP. However, this individual is no longer served by Kelsch Associates.
What can be done to prevent future violations?
The assessment has been revised to add a cue that if a person is not independent with dental hygiene a plan needs to be in place.(Attachment #5)
Who will be responsible for preventing future violations?
Program Director |
08/22/2016
| Implemented |
| 6400.181(e)(14) | Assessment dated 4/5/15 did not document Individual #1's knowledge 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. | Why is the regulation important?
This is important to ensure the safety of the individual when around water sources.
How was the regulation violated?
According to the Citation in CLS the Assessment dated 4/5/15 did not document Individual #1's knowledge of water safety and ability to swim. However, this was not on the list of citations shared with us by Licensing staff when they were here doing licensing and in pulling the Assessment dated 4/5/15 there is information in that section of the Assessment speaking to knowledge of water safety and ability to swim.
What caused the violation?
According to the Assessment in the individual¿s file it does not look like there is a citation (will send copy of 4/5/15 assessment)
What can be done right away to fix the violation?
Could have done an addendum to the assessment if necessary. However, as noted we had not been made aware of this citation prior to citations being entered in CLS and by that time the individual has been discharged from our agency.
What can be done to prevent future violations?
The assessment form has been updated/revised to include cues to ensure all areas of the assessment are complete (Attachment #5)
Who will be responsible for preventing future violations?
Program Director |
08/22/2016
| Implemented |
| 6400.181(f) | Assessment dated 4/5/15 was not sent to the support coordinator and plan team at least 30 calendar days for the develpoment of Individual #1's Individual Support Plan (ISP). | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Why is the regulation important?
This regulation is important to ensure the team has had an opportunity to review/give feedback on the Assessment prior to the meeting to ensure all team members are involved with ensure accurate assessment of the individual.
How was the regulation violated?
Assessment dated 4/5/15 was not sent to the support coordinator and plan team at least 30 calendar days for the development of Individual #1's Individual Support Plan (ISP).
What caused the violation?
The person completing the Assessment did not ensure that documentation of sending the Assessment was kept.
What can be done right away to fix the violation?
The team was given a copy of the Assessment at the time of the meeting.
What can be done to prevent future violations?
The Assessment has been updated to provide cues for when and how the Assessment should be sent to the team, including how to preserve the documentation indicating that the Assessment was sent.(Attachment #5)
Who will be responsible for preventing future violations?
Program Director |
08/22/2016
| Implemented |
| 6400.183(4) | Individual #1 is on a 1:1 direct supervision at the community living arrangement and there is no protocol or schedule outlining specific period of time for the Individual to be without direct supervision. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Why is the regulation important?
This regulation is important to ensure that the individual¿s needs are met with the appropriate level of staffing.
How was the regulation violated?
Individual #1 is on a 1:1 direct supervision at the community living arrangement and there is no protocol and schedule outlining specific period of time for the Individual to be without direct supervision
What caused the violation?
The violation was caused by the individual¿s team overlooking the need to have a protocol in place aimed at reducing the need for the intensive level of staffing.
What can be done right away to fix the violation?
The plan was for the team to discuss developing a protocol to reduce the need for the intensive level of staffing. However, prior to a protocol being developed the individual was discharged from our services at the family¿s request.
What can be done to prevent future violations?
To prevent future occurrences with other individual¿s served; a cue has been added to the Assessment to develop a protocol to reduce intensive services if an individual is currently receiving 1:1 supervision.(Attachment #5)
Who will be responsible for preventing future violations?
Program Director, Individual¿s team |
08/22/2016
| Implemented |
| 6400.213(1)(i) | The record for Individual #1 did not document information relating to identifying marks. | 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. | Why is the regulation important?
This is important to be able to identify an individual in the event they get separated from staff and assistance from police and/or others who don¿t know the individual is needed to help locate/identify the individual.
How was the regulation violated?
Record reviewed did not document information relating to identifying marks for Individual #1.
What caused the violation?
The person completing required forms at the time of admission took the photo of the individual but did not attach it to the Photo Description Form and fill out all info on the form.
What can be done right away to fix the violation?
The photo of the individual was attached to the Description of Photo form and all information on the form was filled out and the document placed in the individual¿s file (attachment #3).
What can be done to prevent future violations?
The Client Admissions Checklist form (Attachment #4) was updated to add further direction on the thorough completion of required information.
Who will be responsible for preventing future violations?
Program Directors, Program Support Managers (PSM)/Residential Managers (RM), and clerical staff |
08/22/2016
| Implemented |