| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(i) | Direct Service Worker #1, date of hire 8/6/18, had first aid and cardio-pulmonary resuscitation training completed 4/10/19. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program specialist will monitor training dates and ensure that training in first aid, cardio-pulmonary techniques , and heimlich techniques is completed within the first 6 months of a person's hire. Tracking for need for/ expiration of such training has been added to the agency's software system. [Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the aforementioned tracking system and the scheduling and review process to ensure staff persons are trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation as required. Documentation of the training shall be kept. At least quarterly for 1 year the COO shall audit the aforementioned tracking system and the staff trainings to ensure training in first aid, Heimlich techniques and cardio-pulmonary resuscitation is completed, timely. (DPOC by AES,HSLS on 7/11/19)] |
06/17/2019
| Implemented |
| 6400.141(a) | Individual #1, date of admission 9/24/18, had a physical examination completed 4/5/19. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A copy of the individual's 4/6/2018 physical has been obtained and is placed in the individuals file. Program specialist will ensure this information is obtained prior to admission for any future individuals. [Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure completion of all individuals' physical examinations, timely. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the responsibilities to audit all individuals' physical examinations and the aforementioned tracking system to ensure completion, timely. (DPOC by AES,HSLS on 7/11/19)] |
06/14/2019
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 9/24/18, had a Tuberculin skin test read 4/8/19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Verification of the individuals previous tuberculin test, given on 4/7/2017 and read on 4/10/17 has been obtained and is in in the individuals file. Program specialist will ensure that this information is obtained for future admissions before an individual is admitted. [Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure timely completion of all individuals' physical examinations with all required information including tuberculin skin testing. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the responsibilities to audit all individuals' physical examinations and tuberculin skin testing and the aforementioned tracking system to ensure completion, timely. (DPOC by AES,HSLS on 7/11/19)] |
06/16/2019
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 8/6/18 had a physical examination completed 8/10/18. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | This staff was hired by the agency in anticipation of the program opening, but did not work with the individual until 9/24/18. It was an administrative error that the staff's clearance was completed before the staff's physical. All staff clearances/hire dates have been reviewed and are in compliance. If a staff already works for the agency and transfers to work within this program, a transfer date will be noted along with the date of hire into this program and the clearance should be run at this time, after the physical is complete. The program specialist will review physical dates, along with hire dates to ensure compliance before the staff begins to work in this program. [Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/11/19)] |
06/19/2019
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1, date of hire 8/6/18, had a tuberculin skin test read 8/10/18. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | This staff was hired by the agency in anticipation of the program opening, but did not work with the individual until 9/24/18. It was an administrative error that the staff's clearance for hire into this program was completed before the staff's TB test was read. All staff clearances/hire dates have been reviewed and are in compliance. If a staff already works for the agency and transfers to work within this program, a transfer date will be noted along with the date of hire into this program and the clearance should be run at this time, after the TB test is complete. The program specialist will review TB test dates, along with hire dates to ensure compliance before the staff begins to work in this program.[Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/11/19)] |
06/19/2019
| Implemented |
| 6400.151(c)(3) | The physical examination completed 9/8/18 for Direct Service Worker #2 did not indicate if the staff person was free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physician has been contacted for this staff for completion of this information. All other physicals for staff have been reviewed, and all other staff physicals reflect that the staff are free from communicable disease. Program Specialist will review all future physicals to ensure that this information is accurately reflected. [Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of staff person's physical examinations. Documentation of the training shall be kept. Documentation of the aforementioned audit by the program specialist shall be kept. (DPOC by AES,HSLS on 7/11/19)] |
06/19/2019
| Implemented |
| 6400.163(c) | The psychiatric medication reviews for Individual #1 completed 12/7/18, 2/22/19, and 4/26/19 did not include the necessary dosage of the medications or the need to continue the medications. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The after visit summary form for psychiatric visits has been revised to clarify the diagnosis, the necessary dosage of the medications and the need to continue the medications from the psychiatrist, and this form will be completed at each psychiatric visit. The program specialist will review the form after each visit to ensure all necessary information is present. [Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of the documentation of the reviews of medications prescribed to treat symptoms of a diagnosed psychiatric illness by a licensed physician to ensure all ensure all required information is include and individuals are administered medications as prescribed. Documentation of the training shall be kept. Documentation of the aforementioned audit by the program specialist shall be kept. (DPOC by AES,HSLS on 7/11/19)] |
06/14/2019
| Implemented |
| 6400.167(b) | Individual #1 is prescribed Desonide Cream 0.05% apply topically to the groin twice a day and Clotrimazole Cream USP 1% apply to rashes in groin under Desonide twice a day. These medications are listed on the Individual #1's June 2019 medication administration record as administer as needed and have not been administered in June 2019. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Correct orders have been received from the individual's doctor to show that these medications are to be given as needed, and corrected labels for the medications have been obtained. All medications and physicians orders will be reviewed by the program specialist to ensure that medications are labeled and given accurately. [At least monthly, a designated staff person certified to administer medications shall audit all individuals' physicians' order, medications and medication administration records to ensure all individuals are administered medications as prescribed and documented as required. (Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/11/19)] |
06/25/2019
| Implemented |
| 6400.181(e)(1) | The assessment completed 10/22/18 for Individual #1 did not include Functional strengths and needs. These sections were left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The program specialist will review all future assessments to ensure completion of all areas of the functional assessment to include the strengths, needs, and preferences of the individuals. [As per COO, Individual #1's current assessment has been updated to include all required information. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of individuals' assessments. Documentation of the training shall be kept. At least quarterly for one year, the COO shall audit all individuals' assessment to ensure all required information is included and updated as needed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/11/19)] |
06/17/2019
| Implemented |
| 6400.181(e)(2) | The assessment completed 10/22/18 for Individual #1 did not include interests. This section was left blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The program specialist will review all assessments in the future to to ensure that each section is complete and accurately reflects the likes, dislikes, and interests of the individual.[As per COO, Individual #1's current assessment has been updated to include all required information. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of individuals' assessments. Documentation of the training shall be kept. At least quarterly for one year, the COO shall audit all individuals' assessment to ensure all required information is included and updated as needed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/11/19)] |
06/17/2019
| Implemented |
| 6400.181(e)(12) | The assessment completed 10/22/18 for Individual #1 did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The appropriate format to include recommendations has been obtained and is now in place and will be utilized for all future assessments. The program specialist will ensure full completion of all forms.[As per COO, Individual #1's current assessment has been updated to include all required information. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of individuals' assessments. Documentation of the training shall be kept. At least quarterly for one year, the COO shall audit all individuals' assessment to ensure all required information is included and updated as needed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/11/19)] |
06/17/2019
| Implemented |
| 6400.186(a) | The ISP review for Individual #1 completed 4/10/19 was not signed and dated by the individual. The ISP review for Individual #1 completed 1/15/19 was not signed and dated by the program specialist and the individual. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | A signature and date line for the individual has been added to the ISP review form. A date line has been added to the program specialist signature. Past ISP reviews were reviewed with the individual. The program specialist will review future ISP reviews with the individual as they are completed and before they are sent to the team. [As per COO, Individual #1's ISP reviews have been signed and dated by the individual and the program specialist upon review. Within 30 days of receipt of the plan of correction and upon hire, the COO shall educate the program specialist of the requirements of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for one year, the COO shall audit all individuals' ISP reviews to the individual and program specialist signed and dated the ISP reviews upon review. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/11/19)] |
06/14/2019
| Implemented |