| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(f) | On 3/9/17 at 9:25 AM, the bathroom on the first floor did not have individual clean paper or cloth towels and a trash receptacle. The bathroom on the second floor did not have individual clean paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | New trash cans and paper towels were purchased date of licensing to ensure an ample supply. Staff will complete a weekly visual check to ensure all bathrooms in the home have the proper items. All staff will be re-educated/re-trained on this regulation and the importance of ongoing compliance by 3/31/17. Training documentation will be kept in each staffs individual training record. 82f [Within 30 days of receipt of the plan of correction, all staff working in community homes shall be trained by the program specialist(s) in the agency's procedures for restocking, storage and checks to include that all staff working in community homes shall check for required bathrooms items throughout the course of their daily duties. (AS 3/16/17)]
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03/25/2017
| Implemented |
| 6400.105 | On 3/9/17 at 9:45 AM, a wooden table and chair were within approximately 1 foot of the furnace and hot water heater. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| This issue was immediately rectified at time of inspection and table was moved. Staff will complete a weekly check and quarterly check to ensure all flammable and combustible supplies and equipment are stored away from any heat source. All staff will be re-educated/re-trained on this regulation and the importance of ongoing compliance by 3/31/17. Training documentation will be kept in each staffs individual training record. [Within 30 days of receipt of the plan of correction, all staff working in community homes shall be trained by the program specialist(s) in the agency's procedures for safely utilizing and storing supplies away from heat sources to include that all staff working in community homes shall check to ensure flammable and combustible supplies and equipment are utilized safely and stored away from heat sources throughout the course of their daily duties. (AS 3/16/17)] |
03/25/2017
| Implemented |
| 6400.141(c)(11) | The physical examination completed 3/8/16 for Individual #1 did not include for an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | This individual was admitted to the program in December 2016 from a mental health residential provider. Due to insurance coverage limitations, this resident was unable to obtain another physical upon admission. For instances like this moving forward, an addendum page has been added that program specialists will request be completed that will include all needed regulatory items. A pre-admission packet was updated and will be required for all new admissions moving forward. MYCS Medical Coordinator (RN) will be responsible for reviewing all consumer physicals for new admissions, annually or as needed. This check will be in addition to the program specialist. [Individual #1 had a physical examination completed 3/13/17 which addressed health maintenance needs, medication regimen and the need for blood work at recommended intervals. Within 30 days of receipt of the plan of correction, the manager of residential services shall review the requirements of individual physical examinations as per 64.00.141(c)(1)-(15) with the program specialist(s) and the medical coordinator who will be reviewing individual physical examination to ensure all required areas are included and there are not any required areas left blank and physician orders/recommendations etc are being followed. Documentation of trainings shall be kept. Documentation of reviews by the program specialist(s) and medical coordinator shall be kept. (AS 3/16/17)] |
03/25/2017
| Implemented |
| 6400.141(c)(14) | The physical examination completed 3/8/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This individual was admitted to the program in December 2016 from a mental health residential provider. Due to insurance coverage limitations, this resident was unable to obtain another physical upon admission. For instances like this moving forward, an addendum page has been added that program specialists will request be completed that will include all needed regulatory items. A pre-admission packet was updated and will be required for all new admissions moving forward. MYCS Medical Coordinator (RN) will be responsible for reviewing all consumer physicals for new admissions, annually or as needed. This check will be in addition to the program specialist.[Individual #1 had a physical examination completed 3/13/17 which addressed medical information pertinent to diagnosis and treatment in case of an emergency. Within 30 days of receipt of the plan of correction, the manager of residential services shall review the requirements of individual physical examination as per 64.00.141(c)(1)-(15) with the program specialist(s) and the medical coordinator who will be reviewing individual physical examinations to ensure all required areas are included and there are not any required areas left blank and physician orders/recommendations are being followed. Documentation of trainings shall be kept. Documentation of reviews by the program specialist(s) and medical coordinator shall be kept. (AS 3/16/17)] |
03/25/2017
| Implemented |
| 6400.171 | On 3/9/17 at 9:55 AM, an uncovered plastic cup approximately three quarters full of a frozen red liquid was in the freezer section of the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| This issue was immediately rectified at time of inspection and the uncovered cup was discarded. Staff will complete a visual weekly check of the refrigerator and freezer and ensure all food items are protected from contamination. All staff will be re-educated/re-trained on this regulation and the importance of ongoing compliance by 3/31/17. Training documentation will be kept in each staffs individual training record.[Within 30 days of receipt of the plan of correction, all staff working in community homes shall be trained by the program specialist(s) in the agency's procedures for food protection from contamination while being stored, prepared, transported and stored to include that all staff working in community homes shall check for food being sealed and covered throughout the course of their daily duties. (AS 3/16/17)] |
03/25/2017
| Implemented |