| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.108(b) | There was found an under-sized 1a-10bc fire extinguisher in the kitchen area. | Fire extinguishers with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Regulation: 108 (b): Is there a fire extinguisher with a minimum 2-A10-BC rating located in each kitchen.
Why is the regulation important? This regulation is important for the health and safety of the individuals residing in the home because if a fire were to occur, an appropriate extinguisher needs to be accessible in the kitchen area in order to prevent fires from spreading throughout the home. The kitchen area of the home is high risk for fires.
How was the regulation violated? A fire extinguisher was located in the kitchen area of the home. However it did not meet the 2-A10-BC rating required by regulations.
What Caused the Violation? Fire extinguisher located in the kitchen did not meet rating regulations. Life Sharing Provider Anna Jessy did not purchase the correct fire extinguisher. Program Specialist did not check rating of fire extinguisher upon move in or during monthly monitoring checks at the home.
What can be done right away to fix the violation? Kelsch Associates had an extra fire extinguisher with a 2-A10-BC rating at the agency office. This violation was corrected day of licensing inspection. Program Specialist brought fire extinguisher to site for Life sharing provider to keep in kitchen on 7/12/17.
What can be done to prevent future violations? Life Sharing Specialist will check fire extinguishers during monthly home visits to call life sharing homes. Life Sharing Specialist will check fire extinguisher ratings on newly purchased extinguishers for new life sharing homes, prior to new individuals moving in date in the future.
Who will be responsible for preventing future violations? Life Sharing Specialist, Luz Fragoso. |
07/12/2017
| Implemented |
| 6500.121(c)(3) | Individual #1 's physical examination dated 2/6/17 did not document a diphtheria/tetanus vaccination. | Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Regulation: 121- C (3): Does the physical examination include immunizations for individuals 18 years or older?
Why is the regulation important? This regulation is important because having the current and accurate immunization history of an individual to provide to health care physicians can prevent infectious disease and promote healthy medical future.
How was the regulation violated? This regulation was violated because there was no immunization history documented on individual #1¿s annual physical exam completed on 2/6/2017. This section was left blank.
What Caused the Violation? During the time of exam individual #1 was living with Brian¿s House as an emergency respite. Brian¿s House did not have medical immunization history for the individual when the physical exam was completed. Individual moved into Kelsch Associates on 4/14/2017.
What can be done right away to fix the violation? Program Specialist obtained immunization history for individual #1 from primary care physician and day program life time medical history. Individual #1¿s medical information was updated in agency electric medical system Therap and annual physical form was updated with immunization information. See attached document #3
What can be done to prevent future violations? Immunization record has been recorded in the Therap System and will be recorded on each annual physical examination form in the future.
Who will be responsible for preventing future violations? Program Specialist, Luz Fragoso. |
07/17/2017
| Implemented |
| 6500.151(a) | Individual #1 's date of admission was 4/14/17 and the assessment was dated 7/11/17. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the family living home. | Regulation: 151(a): Each individual shall have an initial assessment with 1 years prior to or 60 calendar day after admission to the family home and updated assessment annually thereafter.
Why is the regulation important? This regulation is important because the assessment alerts team¿s members of changes and current needs of the individual in order to update ISP with the most current and accurate information to better serve the individual.
How was the regulation violated? Individual #1 admission date to Kelsch Associates was on 4/14/17, prior to move in an ISP assessment was completed on 1/6/2016. An updated assessment was not completed 60 days after move in date to Kelsch Associates.
What Caused the Violation? Changes to administration in Life Sharing Program Specialist role during this time was not aware of assessment schedule or regulation related to new admissions. Individual #1 was first new client admission for program specialist.
What can be done right away to fix the violation? Once aware the 60 day assessment being overdue, program specialist completed an updated assessment on 7/11/17 and sent to team members via email. See attached document #2.
What can be done to prevent future violations? 6500 assessment regulations were reviewed with program specialist and trained in assessment tracking system used by agency. 60 days assessments will be completed within the 60 day time frame for any new admissions in the future.
Who will be responsible for preventing future violations? Program Specialist, Luz Fragoso and Quality Assurance Director Lisa McGough |
07/11/2017
| Implemented |