| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's personal property inventory was last updated 4/12/2019. The inventory only included clothing, a wallet, an animal trap, sunflower seeds, and a cooler. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A full personal property inventory was completed on 4/1/2020 by the house supervisor (see attachment #17).
The house supervisor was trained on keeping an up-to-date personal property record at the home on 3/26/2020 (see attachment #13). Supervisors of all other homes have been trained prior and have completed an up-to-date property inventory record for each individual.
House supervisors will review personal property records monthly to ensure that all new property was added and any discarded property was removed. Changes to property records shall be sent to the CEO monthly so that they may be reviewed for compliance.
The CEO will complete in home assessments, including review of personal property records, no less than once every six months to ensure compliance. |
04/01/2020
| Implemented |
| 6400.77(b) | The first aid kit did not contain tweezers and scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On 2/28/2020, tweezers and scissors were purchased at Walmart and placed in the first aid kit (see attachment #7 and #8).
House supervisors are responsible for ensuring that all homes are in compliance with physical site regulations to include the required contents of first aid kits. On 3/24/2020 the house supervisor of was trained on completing monthly inspections on all physical site regulations (see attachment #11). All supervisors of all other homes have been trained prior and complete monthly inspections of physical site regulations to ensure compliance.
House supervisors will continue to complete monthly inspections of all physical site regulations. The CEO will complete in home assessments of all physical site regulations no less than once every six months to ensure compliance. |
03/24/2020
| Implemented |
| 6400.82(e) | The main bathroom with tub did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | On 2/28/2020, a bath mat was purchased at Walmart and placed in the bathtub (see attachment #7 and #8).
House supervisors are responsible for ensuring that all homes are in compliance with physical site regulations including the requirement of a nonslip surface or mat in all bathtubs and showers. On 3/24/2020 the house supervisor of was trained on completing monthly inspections on all physical site regulations (see attachment #11).
All supervisors of all other homes have been trained prior and complete monthly inspections of physical site regulations to ensure compliance.
House supervisors will continue to complete monthly inspections of all physical site regulations in all homes. The CEO will complete home assessments of physical site regulations no less than once every six months to ensure compliance. |
03/24/2020
| Implemented |
| 6400.141(a) | Individual #1's physical was late. It was completed 1/9/2019 and not again until 1/30/2020.
Medical history is not updated with 2020 physical. It is the 2018 medical history. Medication list attached to physical was updated as of August 2018. Diet states as tolerated; Dr. orders no soda, one treat per day 6/11/19 family practice. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The medical support supervisor will now oversee all medical operations in the homes. The medical coordinator will track all appointment dates of all individuals and ensure that appointments are scheduled and occur within the required dates as required by regulation. The medical support supervisor will pre-populate all physical forms to ensure that all required sections and accurate diagnoses are included on the physical. All medical coordinators are responsible for reporting to the medical support supervisor. If a physical exam is rescheduled or is unable to be completed by the required date, medical support shall include documentation in the individual's records explaining why the physical occurred outside of the required time. Such documentation shall be attached to the physical upon completion. The program specialist/medical coordinator responsible for individual #1 did not follow proper procedures and is no longer employed by Mattern House.
On 6/11/2019, doctor orders were given to limit individual #1 to no soda and one treat per day. Emails were sent to individual #1's support coordinator on 6/18/19, 6/21/19, 7/2/19 and 10/29/19 requesting that individual #1's individual plan be updated to reflect such changes (see attachment #10(a), 10(b), 10(c)). To date, these changes have not been updated in the individual plan by the support coordinator.
The medical support supervisor has already implemented a process for to review all physicals prior to due dates to ensure that all required information is included and up to date. The medical support supervisor oversees all medical operations. Prior, this service was not expanded. Effective 4/7/2020, the medical support supervisor will oversee all medical operations in Somerset.
The CEO will review all records, both in the home and program office, no less than once every six months to ensure compliance. |
04/07/2020
| Implemented |
| 6400.181(a) | The most current assessment in individual #1's record at the home was dated back to 2017. Staff #1 stated "she is working on the current assessment". Mattern House was eventually able to fax me copies of individual #1's assessments dated 2/6/2018 and 5/21/2019. The 2019 assessment was late. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. | Individual #1's assessment was completed on 6/4/2019. The completed assessment has been updated in the individual's records both at home and the program office (see attachment #1) on 3/25/2019. The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed by Mattern House.
The program specialist is responsible for completion of assessments and ensuring that completed assessments are kept on file in the individual's records both at home and at the program office. All program specialists were retrained on 4/6/2020 on the importance of completing assessments annually by the required date and the process of sending all assessments to the program director for review (see attachment #15). All records have been reviewed and assessments have been filed in the individuals' records. |
04/06/2020
| Implemented |
| 6400.214(a) | Individual #1's individual plan signature sheet was not kept in the home record. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | An email was sent to individual #1's support coordinator on 3/24/2020 to request a copy of the signature sheet from individual #1's plan meeting (see attachment #3 and #4). The support coordinator stated she did not have this documentation and asked that the program specialist reach out to the prior support coordinator. An email request was sent to the prior support coordinator. No response has been received as of yet. The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed by Mattern House.
The program specialist is responsible for keeping a copy of the signature sheet sent from the support coordinator which shows the names of those who attended and participated in the planning process. All individuals' records were reviewed to ensure that a signature sheet was on file. The program specialist were trained on 4/6/2020 to send a written request to any support coordinator from whom they did not receive a signature sheet. Such correspondence shall be filed in the individual's record both at the home and program office (see attachment #15).
The program director will track due dates of all assessments and ensure completion by the required date. The program specialist is responsible for sending all assessments to the program director for review prior to delivery to the team. The program director shall ensure that a list of all team members is kept. The program director shall ensure that any correspondence made to request missing documentation from a support coordinator is kept in the individual's record both at the home and the program office.
The CEO will review all records, both at the home and program office, no less than once every six months. |
04/06/2020
| Implemented |
| 6400.34(a) | There were no documentation that the home informed and explained individual rights and the process to report a rights violation to individual #1. No such documentation was kept at his home. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual #1 and individual #1's designated persons signed the 'Mattern House, Inc. Nondiscrimination in Services/Health Care Consent' on 12/31/2019 which states "I have read or have had the Individual Bill of Rights explained to me" and "I have read and understand the written Grievance Policy and Procedures of Mattern House, Inc."(see attachment #6). The consent was updated in individual #1's records on 3/26/2020 both at the home and program office.
Mattern House, Inc. has reviewed all individual records to ensure they include an updated Nondiscrimination in Services/Health Care Consent form.
The Mattern House, Inc. training coordinator is responsible for updating the Consent form annually and ensuring that each consent is signed and filed in each individual's record. The training coordinator will begin the process of updating new consents in October of each year to give sufficient time for individuals and their designated persons to sign and return so that consents may be filed in a timely manner.
The CEO will review all records, both in the home and program office, no less than once every six months to ensure compliance. |
03/26/2020
| Implemented |
| 6400.44(b)(1) | The most current assessment in individual #1's record at the home was dated back to 2017. Staff #1 stated "she is working on the current assessment". Mattern House was eventually able to fax me copies of individual #1's assessments dated 2/6/2018 and 5/21/2019. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | Individual #1's assessment was completed on 6/4/2019. The completed assessment has been updated in the individual's records both at home and the program office (see attachment #1) on 3/25/2020.
All program specialists were retrained on 4/6/2020 on the importance of completing assessments following all required by regulations (see attachment #15). The program specialists were updated on the process of submitting all completed assessments to the program director for review prior to delivery so that they may be monitored for accuracy and timeliness. All records have been reviewed and assessments have been filed in the individuals' records.
The program specialist is responsible for completion of assessments to suit all regulatory requirements. The program director will track the due dates of all assessments and ensure completion by the required date. The program specialist is responsible for sending all assessments to the program director for review prior to delivery.
The CEO will review all files, both in the home and program office, no less than once every six months to ensure compliance. |
04/06/2020
| Implemented |
| 6400.44(b)(2) | There is no documentation that the program specialist participated in the individual plan process, development, team reviews and implementation in accordance with this chapter. Staff #1 did not have a current sign-in sheet from the current individual plan meeting. Also, individual #1's individual plan speaks of a behavioral plan for individual #1. As of this date, staff #1 states individual #1 is no longer following a behavioral plan. Staff #1 stated that there was a meeting in January 2020 and individual #1's mother wanted him to stop the behavioral supports. The behavioral support plan for individual #1 had his roommate's name, "individual #2" scattered throughout the document. The behavioral Plan dates active for the time period 5/1/2019 to 4/30/2020. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | An email was sent to individual #1's support coordinator on 3/24/2020 to request a copy of the signature sheet from individual #1's plan meeting (see attachment #3 and #4). The support coordinator stated that she does not have the documentation and suggested reaching out to the prior support coordinator. The support coordinator has not responded as of yet.
On November 21, 2019, individual #1's team met for a behavior support meeting. At this meeting, it was discussed that individual #1 had shown a decrease in behaviors and therefore the team agreed it was appropriate to terminate behavior support services effective November 30, 2019 as noted on Quarterly Progress Note (see attachment #5). The team decided that staff should continue to monitor behaviors by use of daily service notes. On March 25, 2020 individual #1's staff removed all behavior tracking sheets from the records in the home. The program specialist sent an email request to the support coordinator on March 25, 2020 asking to modify individual #1's plan to reflect the change in behavior support services (see attachment #14). The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed by Mattern House.
The behavior support plan that was on file which had individual #2's name throughout was not the correct behavior support plan. The correct behavior support plan has been updated in individual #1's records (see attachment #16).
All program specialists were retrained on 4/6/2020 on the importance of participating in the individual plan process, development, team reviews and implementation with the Chapter 6400 regulations, to include making timely revisions to ISPs and Assessments regarding change in services (see attachment #15). The program director will review summaries of all team meetings and follow-up in the home and at the program office.
The CEO will review all records, both at the home and program office, no less than once every six months to ensure compliance. |
04/06/2020
| Implemented |
| 6400.181(f) | There is no documentation that the staff #1 provided the assessment 5/21/2019 to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual #1's assessment was completed late on 6/4/2019. The assessment was completed late and therefore could not be sent to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The completed assessment includes a cover sheet and face sheet which lists the support coordinator and team members to whom the assessment was sent (see attachment #1). The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed with Mattern House.
The program specialist is responsible for providing completed assessments to the individual plan team members at least 30 calendar days prior to the individual plan meeting. In order to be compliant with 6400.181(f) the program specialist is required to ensure that an individual's assessment is updated annually. The program specialist failed to complete the assessment by the required date. The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed with Mattern House.
The program specialists were all retrained on the importance of providing the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting on 4/6/2020. Program specialists work completed will be monitored by the program director as each due date approaches.
The program director will track the due dates of all assessments and ensure completion by the required date. The program specialist is responsible for sending all assessments to the program director prior to delivery for review.
The CEO will review all records no less than once every six months to ensure compliance. |
04/06/2020
| Implemented |
| 6400.182(a) | Staff #1 states individual #1 is no longer following a behavioral plan. Staff #1 stated that there was a meeting in January 2020 and individual #1's mother wanted him to stop the behavioral supports. There is no documentation to coordinate the plan and update the individual plan. Also, the staff that work with individual #1 are still keeping tracking of the behavioral documentation from said plan. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | On November 21, 2019, individual #1's team met for a behavior support meeting. At this meeting, it was discussed that individual #1 had shown a decrease in behaviors and therefore the team agreed that it was appropriate to terminate his behavior support services effective November 30, 2019. The team decided that staff should continue to monitor behaviors by use of daily service notes. On March 25, 2020 individual #1's staff removed all behavior tracking sheets from records in the home. The program specialist sent a request on March 26, 2020 to the support coordinator to modify individual #1's plan to reflect the change in behavior support services (see attachment #4). The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed with Mattern House.
All program specialists were retrained on 4/6/2020 on the importance of coordinating the development of the individual plan including revisions with the individual and individual plan team and to update the CEO and/or program director with a summary of all team meetings so revisions may be tracked (see attachment #15).
Program specialists are responsible for coordinating the development of the individual plan, including revisions with the individual plan team. The program specialist will send a summary of all team meetings to the program director. The program specialist shall report the submission of all individual plan revisions to the program director upon completion.
The program director shall monitor all changes in the development of the individual plan and/or revisions made to an individual's plan. The program director shall monitor all program services by reviewing program service reports as they are completed.
The CEO will review all records, both at the home and program office, no less than once every six months to ensure compliance. |
04/06/2020
| Implemented |
| 6400.183(b) | There is no documentation of who was present at the individual #1's current individual plan team meeting. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | An email was sent to individual #1's support coordinator on 3/24/2020 to request a copy of the signature sheet from individual #1's plan meeting (see attachment #3 and #4). The support coordinator stated she did not have the signature sheet and directed the program specialist to reach out to the prior support coordinator. The prior support coordinator has not responded as of yet. The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed with Mattern House.
The program specialist is responsible for keeping a copy of the signature sheet sent from the support coordinator which shows the names of those who attended and participated in the planning process. All individuals' records have been reviewed to ensure a signature sheet from the plan meeting was on file. All program specialists were trained on 4/6/2020 the proper procedures of obtaining and/or requesting signature sheets and filing any correspondence for requests in the individual's file (see attachment #15).
Mattern House has employed a program director will track due dates of all assessments and ensure completion by the required date. The program specialist is responsible for sending all assessments to the program director prior to delivery to the team for review. The program director shall ensure that any correspondence made to request documentation from a support coordinator is kept in the individual's record both at home and at the program office if the signature sheet is not received.
The CEO will review all records, both in the home and the program office, no less than once every six months to ensure compliance. |
04/06/2020
| Implemented |
| 6400.183(c) | There is no documentation of who participated in individual #1's current Individual plan team meeting. | The list of persons who participated in the individual plan meeting shall be kept. | A list of persons participating in the individual plan meeting is kept to ensure that the individual plan is understood by all of the individual's natural and formal supports. A list of team members is documented on both the cover letter and face sheet of the individual's annual assessment for individual #1 dated 6/4/2019 (see attachment #1) includes the annual assessment with the attached cover letter which lists the persons participating in the individual's plan meeting. The individual's records both at the home and the program office have been updated to include the completed assessment and cover letter. An email was sent to individual #1's support coordinator on 3/24/2020 to request a copy of the signature sheet from individual #1's plan meeting (see attachment #3 and #4). The current support coordinator stated she did not have the signature sheet and directed the program specialist to reach out to the prior support coordinator. The prior support coordinator has not responded as of yet. The program specialist responsible for individual #1 did not follow proper procedures and is no longer employed with Mattern House.
The program specialist is responsible for ensuring that the list of persons participating in the individual plan meeting is kept. The program specialist is responsible for completing all assessments and delivering to the support coordinator and listed team members no later than 30 days prior to the date of the individual plan meeting. The program specialist is responsible for keeping a copy of the signature sheet sent from the support coordinator which shows the names of those who attended and participated in the planning process. All individual's records have been reviewed to ensure a signature sheet from the plan meeting was on file. All program specialists were trained on 4/6/2020 on the proper procedures to obtain signature sheets to include a written request to the support coordinator if the signature sheet is not received within 30 days of the plan meeting (see attachment #15). Such correspondence shall be filed in the individuals' records both at the home and the program office.
The program director will track all due dates of all assessments and ensure completion by the required date. The program specialist is responsible for sending all assessments to the program director for review prior to delivery to the team. The program director shall ensure that a list of all team members is kept. The program director shall ensure that any correspondence made to request missing documentation from a support coordinator is kept in the individual's record both at the home and program office.
The CEO will review all records, both at the home and program office, no less than once every 6 months to ensure compliance. |
04/06/2020
| Implemented |