| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Four instant ice packs, which indicated to contact posion control if ingested, were unlocked in the first aid room. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All ice packs were removed from the first aid cabinet. They are now in a locked cabinet in the Program Manager¿s office. Attachment # 3 shows the first aid kit with no ice packs. There is a monthly site monitoring of the physical facility that will be completed by the Program Manager and she was trained on 10/24/16. |
10/24/2016
| Implemented |
| 2380.55(a) | There were brown stains on the wall, dirt and grime on the walls and radiator, and rust spots on the floor in the corner of the women's restroom. | Clean and sanitary conditions shall be maintained in the facility. | The rust spots on the floor would not come off, leaving our only option to replace the tiles. With our building about to be completely renovated with renovations starting in the spring of 2017, this will occur then. The bathroom was cleaned, removing the dirt from the walls and radiator. There is a monthly site monitoring of the physical facility that will be completed by the Program Manager and she was trained on 10/24/16. |
10/24/2016
| Implemented |
| 2380.55(d) | The trash cans in the main program area, women's restroom, and lunch area were not covered. | Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents. | Lids were purchased for the trash cans. Attachment #1 shows the trash can with the lid. These trash cans are in the first aid room, kitchen, lunch area, program area, and restrooms. There is a monthly site monitoring of the physical facility that will be completed by the Program Manager and she was trained on 10/24/16. |
10/24/2016
| Implemented |
| 2380.55(e) | The trash receptacle outside the facility was uncovered. | Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents. | This trash can was removed from the area. Attachment #2 shows the area where the receptacle was removed. There is a monthly site monitoring of the physical facility that will be completed by the Program Manager and she was trained on 10/24/16. |
10/24/2016
| Implemented |
| 2380.58(a) | The cement wall in the Movement room had large areas of peeling paint. There was peeling paint and a large hole in the drywall, approximately one to two feet, in the TV room. There was a large pipe protruding from the wall with exposed spray insulation in the TV room. | Floors, walls, ceilings and other surfaces shall be in good repair. | Attachment #7 shows the picture of the hole being repaired. Our entire building, every square foot, is going to be renovated in the next year. Construction is scheduled to being in the spring of 2017. Therefore, the walls that need an excessive amount of paint will be repaired during the construction. There is a monthly site monitoring of the physical facility that will be completed by the Program Manager and she was trained on 10/24/16. |
10/24/2016
| Implemented |
| 2380.111(a) | Individual #1's 10/7/15 physical exam was completed late. The previous physical exam was completed on 9/4/14. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Attachment #4 is the last two years of physicals for an individual that were completed within the allotted timeframe. During the monthly audits of files by Program Manager and Administrator, physicals will be checked for when they are due. Any upcoming physicals will have letters sent home to his/her caregiver. This letter will be kept in their site file. All programming staff have been trained to review this information on 10/24/16. |
10/24/2016
| Implemented |
| 2380.111(c)(1) | Individual #2's 8/19/16 physical exam did not include a medical history. | The physical examination shall include: A review of previous medical history. | Attachment #4 is the last two years of physicals for an individual that have the medical histories attached. During the monthly audits of files by Program Manager and Administrator, physicals will be checked to ensure the medical histories are attached. All programming staff have been trained to review this information on 10/24/16. |
10/24/2016
| Implemented |
| 2380.111(c)(5) | Individual #1's 10/3/14 Tuberculin test was administered after his/her admission to the facility on 7/14/14. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Attachment #4 is the last two years of physicals for an individual, in which the Tuberculin test was administered the allotted timeframe. During the monthly audits of files by Program Manager and Administrator, physicals will be checked for when vaccinations need to be done. Any upcoming vaccinations will have letters sent home to his/her caregiver. This letter will be kept in their site file. All programming staff have been trained to review this information on 10/24/16. |
10/24/2016
| Implemented |
| 2380.111(c)(10) | Individual #3's 12/1/15 physical exam did not include 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. | Attachment #4 is the last two years of physicals for an individual, in which all sections of the physical are completed. During the monthly audits of files by Program Manager and Administrator, physicals will be checked for thoroughness and completion of all sections. All programming staff have been trained to review this information on 10/24/16. |
10/24/2016
| Implemented |
| 2380.176(a) | Individual #1's program information was unlocked in the main program area. Two prevocational clients' records were unlocked in the main program area. | Individual records shall be kept locked when they are unattended. | Dodi Curtis, Community Activities Program Manager, has moved a lockable cabinet, where all goal books and confidential information can be stored. See Attachment #6-contains photo of the locked cabinet. The Program Manager will ensure all confidential information is stored in this cabinet. All direct support staff were informed. |
10/27/2016
| Implemented |
| 2380.181(e)(13)(vi) | Individual #1's 5/2/16 assessment, Individual #2's 4/29/16 assessment, and Individual #3's 4/25/16 assessment did not include progress over the past year in community integration. | The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. | Attachment #5 demonstrates the community integration section of an assessment, including the progress over the past year. Dodi Curtis, Community Activities Program Manager, will be reviewing all future assessments to ensure the appropriate information is in the section of community integration in each individual¿s assessment. Progress or regress will be described in this area. All site files of the individuals currently in the ATF program have been audited by the Program Manager and Administrator to ensure this information is being captured correctly. There will continue to be monthly audits on site files completed by the Program Manager and Administrator. All programming specialists have been trained on how to incorporate this information into the assessments on 10/24/16. |
10/24/2016
| Implemented |
| 2380.186(c)(1) | Individual #2's 7/25/16 Individual Support Plan (ISP) review did not include progress and participation toward his/her social skills outcome. | The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | Attachment #8 is the ISP review from 7/25/16 and from 10/25/16, which includes progress and participation towards his social skills outcome. Programming Specialists will be reviewing all future ISP reviews to ensure the appropriate progress/regress is documented in all sections. All site files of the individuals currently in the ATF program have been audited by the Program Manager and Administrator to ensure this information is being captured correctly. There will continue to be monthly audits on site files completed by the Program Manager and Administrator. All programming specialists have been trained on how to incorporate this information into the assessments on 10/24/16. |
10/25/2016
| Implemented |