Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235328 Renewal 11/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 11/29/2023 at 10:17am, the water temperature in the main floor full bathroom measured 122.7°F when taken at the sink. On 11/29/2023 at 10:23am, the water temperature at the kitchen sink measured 125.2°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The heat source issues were resolved on 12/5/23 by the BLARS maintenance department (the needed parts had to be ordered). The water temperatures are now in compliance. 12/31/2023 Implemented
6400.68(b)On 11/29/2023 at 10:20am, the water temperature in the main floor full bathroom measured 122.3°F when taken at the shower. Hot water temperatures in bathtubs and showers may not exceed 120°F. The heat source issues were resolved on 12/5/23 by the BLARS maintenance department (the needed parts had to be ordered). The water temperatures are now in compliance. 12/31/2023 Implemented
6400.141(c)(1)Individual #2's annual physical examination, completed on 1/23/2023, does not include a review of the individual's previous medical history. This section was left blank on the physical examination form.The physical examination shall include: A review of previous medical history. Moving forward water temperatures will be taken every two weeks and logged on the ¿Bi-Monthly Check Sheets¿ that is turned in to the Program Specialist. If there is ever a temperature that is outside of the regulatory standards, the maintenance department will be contacted immediately to have the issue rectified. The Program Specialist will be responsible for monitoring this area and will maintain the Bi-Weekly Check Sheets in his office. 12/31/2023 Implemented
6400.141(c)(3)Individual #2's annual physical examination, completed on 1/23/2023, does not include immunizations for individuals 18 years of age or older. [Repeat violation: 12/7/2022, et al.]The physical examination shall include: 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. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (immunizations). The second option will be that the BLARS Lead Nurse populate the ¿immunization history¿ section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(4)Individual #2's annual physical examination, completed on 1/23/2023, does not include a hearing screening. This section was left blank on the physical examination form.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (hearing screening). The second option will be that the BLARS Lead Nurse populate the ¿hearing screening¿ section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(10)Individual #2's annual physical examination, completed on 1/23/2023, does not indicate if the individual is free of all communicable disease or specific precautions that must be taken to prevent spread of the disease to other individuals. This section was left blank on the physical examination form.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (free of all communicable diseases or specific precautions that must be taken to prevent spread of the disease to other individuals). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(14)Individual #1's annual physical examination, completed on 6/26/2023, does not include medical information pertinent to diagnosis and treatment in case on an emergency. This section was left blank on the physical examination form. Individual #2's annual physical examination, completed on 1/23/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank on the physical examination form. [Repeat violation: 12/7/2022, et al.]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The BLARS nursing staff will reach out to individual #1¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (medical information pertinent to diagnosis and treatment in case of an emergency). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.143(a)Individual #2 was scheduled to receive their DT immunization booster on 1/4/2023. Individual #2 refused the vaccination at the scheduled appointment. No further attempts to obtain this vaccination have been made and there is no documentation of continued attempts to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The BLARS Lead Nurse contacted Individual #1¿s physician and ordered the supplies for the DT immunization booster; this occurred on 12/4/23. Once those supplies are in, the nurse will attempt to administer the shot to the individual in his home environment; he may be more comfortable and receptive in that setting. Training and education with this individual would be difficult due to his cognitive limitations. 12/31/2023 Implemented
SIN-00216225 Renewal 12/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)The financial record for Individual #1, date of admission 11/15/2006, stated the current balance as of 12/08/2022 should be $773.54. The house supervisor indicated he gave $10 from the cash on hand to Individual #1 for today's lunch and forgot to document it. That would bring our balance to $763.54. The cash on hand in the home was counted as $790.60 on 12/08/2022. The cash on hand is $27.06 more than what was documented. The financial record for Individual #2, date of admission 6/30/2000, stated the current balance as of 12/08/2022 should be $1,440.90. The house supervisor indicated he gave $10 from the cash on hand to Individual #2 for today's lunch and forgot to document it. That would bring our balance to $1,430.90. The cash on hand in the home was counted as $1,424.89 on 12/08/2022. The cash on hand is $6.01 less than what was documented.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. The financials for individual #1 and individual #2 have been reconciled by the Residential Manager and are currently and up-to-date and accurate. 01/10/2023 Implemented
6400.141(c)(9)The most recent prostate exam for Individual #1 was completed on 6/22/2021. Individual #1 is 40 years of age or older. This exceeds the annual requirement.The physical examination shall include: A prostate examination for men 40 years of age or older. Client #1 did, in fact, have his prostrate exam done timely; it was completed on 6/22/22 (this report was not available at the time of the survey). This document will be forwarded separately with other supporting documentation. Client #1¿s 2023 prostate exam has already been scheduled for June 2023. 01/11/2023 Implemented
6400.181(e)(12)Individual #1's assessment, completed on 7/21/2022, does not include recommendations for specific areas of training, programming and services. Individual #2's assessment, completed on 11/17/2022, does not include recommendations for specific areas of training, programming and services [Repeat violation 1/04/22, et. al.].The assessment must include the following information: Recommendations for specific areas of training, programming and services. Individual #1 and #2¿s assessments did include a paragraph at the end of the assessment to address the assessments however the recommendations for specific areas of training, programming and services was not included. There will now be a separate area after the paragraph to address the aforementioned areas. In addressing individual #1 and #2, these will be reassessed by 1/20/23 and with recommendations for specific areas of training, programming and services. 01/20/2023 Implemented
6400.46(a)Direct Service Worker #2, date of hire 9/07/2022, has not been trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered [Repeat violation 1/04/22, et al.].Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Direct Service Worker #2 is schedule to take fire safety training on 1/20/23 (which is the next scheduled class). 01/20/2023 Implemented
6400.51(b)(1)Direct Service worker #2 did not complete the following training topic prior to working alone with individual and within 30-days after hire: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Direct Service Worker #3, date of hire 12/14/2021, did not complete the following training topic prior to working alone with individual and within 30-days after hire: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. [Repeat violation 1/04/22, et al.].The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Direct Service Worker #2 did complete training on application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships, however it was not within 30 days and prior to working alone. 02/01/2023 Implemented
6400.51(b)(3)Direct Service Worker #3 did not complete the following training topic prior to working alone with individual and within 30-days after hire: Individual rights [Repeat violation 1/04/22, et al.].The orientation must encompass the following areas: Individual rights.Direct Service Worker #3 did complete individual rights, however it was not within 30 days and prior to working alone. 02/01/2023 Implemented
6400.52(c)(1)Executive Director #1, date of hire 5/16/1988, did not complete the following training during the annual training year 1/1/2021 through and including 12/31/2021: The application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships [Repeat violation 1/04/22, et. al.].The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training record for the Executive Director did not include Person Centered Planning, Community Integration, Individual Choice and Supporting individuals to develop and maintain relationships. The Executive Director will have all of these trainings completed by 1/24/23. 02/01/2023 Implemented
6400.52(c)(3)Executive Director #1 did not complete the following training topic during the annual training year 1/1/2021 through and including 12/31/2021: Individual rights [Repeat violation 1/04/22, et. al.].The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The annual training record for the Executive Director did not contain individual rights. The Executive Director complete this training by 1/24/23. 02/01/2023 Implemented
6400.165(g)Individual #1 is prescribed a medication used to treat symptoms of a psychiatric illness. A review was not completed from 1/1/2022 through 6/02/2022. This exceeds the 3-month requirement. Individual #2 is prescribed a medication used to treat symptoms of a psychiatric illness. A review was not completed from 1/12022 through 6/02/2022.This exceeds the 3-month requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 and Individual #2 both were missing the Psychiatric review that should have been completed between 1/1/22 and 6/2/22. 02/01/2023 Implemented
6400.181(f)Individual #2's assessment completed on 11/17/2022 was provided to the individual plan team members on 11/17/2022 for the annual individual plan meeting held on 11/18/2022.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 #2¿s yearly assessment was late to the Support Coordinator 02/01/2023 Implemented
SIN-00198428 Renewal 01/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)The agency serves as the representative payee for Individual #1. On 1/5/22 at 12:00 pm, there was no financial ledger found onsite to account for their cash-on-hand, totaling $395. The agency serves the representative payee for Individual #2. On 1/5/22 at 12:04 pm, there was no financial ledger found onsite to account for their cash-on-hand, totaling $42. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. A transaction ledger has been initiated for all the clients at 102 Williams St. Group Home and these ledgers will be reconciled and monitored by the shift manager on all shifts that they work. 02/21/2022 Implemented
6400.66On 1/5/22 at 11:30 am, Individual #1's ensuite bathroom did not have a functioning light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The nonfunctioning light bulb was changed on 1/5/22 and the light is currently in working order. 02/21/2022 Implemented
6400.104The notification to the local fire department did no address the home's capacity and layout; a general description of the mobility needs of the individuals served; and the exact locations of their bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The Program Specialist is developing a form that will address the homes capacity and layout, the description of each individual¿s mobility needs as well as exact locations of each individual¿s bedroom. This form will be utilized by the local fire department in addition to their typical document in an effort to meet the stipulations of this requirement. 02/21/2022 Implemented
6400.110(a)On 1/5/22 at 11:25 am, there was no operable smoke detector in the basement of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. After consulting with the maintenance supervisor, there are, in fact, heat sensors tied in with the simplex system at 102 Williams in the basement. There is one located in each room of the basement; they can be found on the Johnson controls report of inspection for fire system. We have removed the old battery operated head and the one predating the simplex units as well. Implementation is ongoing in this area. 02/21/2022 Implemented
6400.112(c)The written fire drills record for the fire drill conducted on 3/27/21 did not indicate the exit route used. [Repeat violation from 2021.]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill report was changed from alternative exit used to just state the actual exit that was used to eliminate the confusion from the staff. The new fire drill reports will begin immediately. 02/21/2022 Implemented
6400.141(c)(3)Individual #2's immunization record indicates they received their most recent Tetanus immunization on 1/21/02.The physical examination shall include: 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. The nursing department is in the process of scheduling Individual #2¿s Tetanus shot. This will be completed by 2/21/22. Additionally, all client records were checked and a spreadsheet will be completed by the nursing department to monitor immunizations for compliance. 02/21/2022 Implemented
6400.141(c)(12)Individual #2's physical examination completed 12/15/21 did not include physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual. The physical exam form was revised by our lead nurse to address if the client has any physical limitations. 02/21/2022 Implemented
6400.141(c)(14)Individual #2's physical examination completed 12/15/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical form was revised by our lead nurse to insure that the area of assessment for individual¿s medical information pertinent to diagnosis and treatment in case of emergency are complete. 02/21/2022 Implemented
6400.142(g)Individual #1 is not independent in the area of dental hygiene. Their record included a dental hygiene plan from 4/20/21 but no plan completion from 2020 to show demonstrate annual compliance. Individual #2 is not independent in the area of dental hygiene. Their record included a dental hygiene plan from 2/4/20 but no plan completion from 2021 to show demonstrate annual compliance.A dental hygiene plan shall be rewritten at least annually. The dental plans have been updated for individuals #1 and #2 and they been added to their records. This update took place on 1/19/22. These records were also sent to the group home for the staff to review and sign off on as well. A copy of the dental plans will be kept at the group home for the staff to refer to when needed. 02/21/2022 Implemented
6400.181(e)(1)Individual #1's 10/14/21 assessment does not address their strengths, needs, and preferences. Individual #2's 1/10/21 assessment does not address their strengths, needs, and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Individual¿s #1 and #2 strength and needs assessments have had preferences added to the assessment. These assessment will be updated by 2/21/22 and then will be completed annually prior to their ISP. 02/21/2022 Implemented
6400.181(e)(2)Individual #1's 10/14/21 assessment does not address their dislikes. Individual #2's 1/10/21 assessment does not address their dislikes.The assessment must include the following information: The likes, dislikes and interest of the individual. Individual #1 and #2 likes and dislikes will be re-evaluated to look at the individual¿s dislikes and to address those needs. These will be re-evaluated by 2/21/22 and then will done annually prior to their ISP. 02/21/2022 Implemented
6400.181(e)(12)Individual #1's 10/14/21 assessment does not address recommendations for specific areas of training, programming, and services. Individual #2's 1/10/21 assessment does not address 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. Individual #1 and #2 assessment will now include a paragraph at the end of the assessment to address recommendations for specific areas of training, programming and services. These will be re-evaluated by 2/21/22 and then will done annually prior to their ISP. 02/21/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 3/19/21. Individual #2 was informed and explained individual rights on 3/15/21. The rights document did not include the following rights: .32m through .32n, to share contact information with whom the individual chooses and to unrestricted and private access to telecommunications; .32r1 through .32r5, to bedroom door locking provided by a key, access card, keypad code or other entry mechanism made accessible to permit them in locking and unlocking the door, to limiting access to their bedroom except in a life-safety emergency or with their expressed permission, to providing assistive technology as needed in allowing them to lock and unlock the door without assistance, to allowing easy and immediate access to their bedroom by themselves and staff persons in the event of an emergency, and to providing the primary caregiver with the key or entry device to lock and unlock the individual's bedroom door; and .32v, to right modifications limited only to the extent necessary to mitigate a significant health and safety risk to the individual or others. [Repeat violation from 2021.]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.The Bill of Rights and Responsibilities was updated by the Program Specialist on 1/12/22 to include .32m through .32n; .32r1 through .32r5; and .32v. The revised Rights and Responsibilities was sent to the guardians for their review and signature and was also sent to the group home for review and signature of the clients who are their own guardian. 02/21/2022 Implemented
6400.166(a)(11)Individual #1's January 2022 Medication Administration Record does not list the diagnosis or purpose for the prescribed Metoprol, Fluoxetine, and Risperidone. Individual #2's January 2022 Medication Administration Record does not list the diagnosis or purpose for the prescribed Amlodipine and Mirtazapine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Effective immediately, when verbal orders are placed in the Order Connect system by the nurse or prescriber the diagnosis will be added to the order description. This will then transfer to the eMAR in the electronic medical record. The pharmacy creates the paper MARS from the orders received through the order connect system so this correction will allow the paper MARs to include the reason and or diagnoses for the prescribed medication. Nursing will inspect the paper MARS before distributing to the programs to ensure all reasons and or diagnosis are listed on the paper MAR to utilize when the computers are down. The lead nurse with the director of nursing¿s guidance will be responsible for monitoring this area and will do monthly checks of the eMAR and paper MAR to ensure these changes are being completed and all required information is documented. This will be fully implemented by 2/21/22. 02/21/2022 Implemented
SIN-00183715 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drills records for the fire drill held on 11/9/2019, 12/4/2019, 1/4/2020, 1/11/2020, 2/13/2020, 5/16/2020, 8/2/2020, 9/3/2020, 10/12/2020, 11/17/2020, and 1/10/2021 did not include the exit route used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The group homes protocol is to label the exit route used during fire drills. The staff obviously failed to document the exit route on numerous occasions. Effective 3/5/21 all fire drill reports will be turned in to the Program Specialist for his review and approval of the fire drill report. If the report is documented thoroughly and accurately, the fire drill will be forwarded to the Director of IDD for his review and filing. Any reports with errors or discrepancies will be returned to the group home to clarify. If the situation warrants, a new fire drill will be conducted. Additionally, all of the staff at 102 Williams Street group home will be re-trained on appropriate procedures for running a file drill and the corresponding documentation. This training will be complete by 3/12/21. All staff will sign off on an ¿on-campus training record¿ to authenticate their attendance at the training. 03/08/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 10/13/2020. The rights document did not include the following rights: 6400.32e, the right to make choices and accept risks; 6400.32f, to refuse to participate in activities and services; 6400.32g, to control his own schedule and activities; 6400.32h, to control his own schedule and activities; 6400.32j, to voice concerns about the services the individual receives; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the Individual's bedroom door; 6400.32s, to have a key, access card, key code or other entry mechanism to lock and unlock an entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.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.The ¿Client Bill of Rights¿ will be revised to add all of the deficient areas as depicted in 6400.34 (a). This revision will be completed and finalized by 3/12/21. During the week of 3/15/21, this newly revised ¿Bill of Rights¿ will be thoroughly explained to all the clients in both group homes; a detailed progress note will be written for each individual once this is completed. The clients will also sign off that this information has been reviewed with them. Additionally, the revised ¿Bill of Rights¿ will be mailed to all the guardians for their review. They will also sign off to authenticate they have received and understand the new Bill of Rights. In order to track compliance in this area, the ¿Bill of Rights¿ will be reviewed during the quarterly record review process that is a standing meeting. Checking annual review of ¿Bill of Rights¿ will now be a part of this process. The Program Specialist will be responsible for monitoring this process for compliance. [A copy of the signed, 3/10/21 rights document was provided to the Department on 3/10/21. (AES,HSLS on 3/10/21)] 03/22/2021 Implemented
6400.46(a)Program Specialist #1 did not complete fire safety training in the year 2020.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The program specialist is currently up to date on fire safety training; he took the class on 2/22/21. Moving forward the Director of IDD and the Program Specialist will review the Human Resources Training records to assure compliance in all required areas. This training check will be documented on a training compliance check sheet. This record will be maintained in the Executive Director office. This process will be started on 3/8/21. 03/15/2021 Implemented
6400.165(g)A review of medications prescribed to treat symptoms of a psychiatric illness was completed with Individual #1 on June 4, 2020 and then again on December 22, 2020.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All waiver group home clients who are on psychiatric medications will be reviewed to assure they are in compliance with the required 3 month medication checks. This will be completed by 3/8/21. Moving forward, the Beacon Light Adult Residential Services Lead Nurse and the Program Specialist will meet monthly to review medications and to assure that scheduled appointments are in place for individuals in need of a medication check due to being on a psychotropic medication. The monthly checks completed by the Lead Nurse and the Program Specialist will be documented on a ¿Medication Check Compliance Form¿ and will be stored in the Executive Director¿s office. 03/15/2021 Implemented
SIN-00146332 Renewal 11/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1 had a review of medications to treat symptoms of a diagnosed psychiatric illness completed 1/18/18 and then again on 5/17/18. The medication review for Individual #1 completed on 7/19/18 did not include the reason for prescribing the medications or the necessary dosages . 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.A new psychiatric med check schedule was implemented on 11/30/18 and now insures that all clients psychiatric medication checks occur every 3 months instead of the four months that was previously happening. The Beacon Light Adult Residential Services nursing staff also added diagnosis and a comment section to the psychiatric medication check form to further improve the documentation process. This form will be given to the physician by our nursing staff for completion and will be maintained in the nursing files. This process will be monitored by the Specialty Programs Director and the BLARS Nurse Manager. [Upon completion, a designated staff person educated in the requirement of psychiatric medication review shall audit the review documentation to ensure all required information is included and individuals are administered medications as prescribed. Documentation of the audits shall be kept. (DPOC by AES on 12/20/18)] 01/17/2019 Implemented
SIN-00126576 Renewal 12/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)Chief Executive Officer #1, date of hire 5/16/88, had 9.75 hours of training relevant to human services or administration during the training year from 1/1/16 to 12/31/16. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Each calendar year the Executive Director of Beacon Light Adult Residential Services (BLARS) will complete at least 24 hours of training. In addition to regularly scheduled training mandated by the agency, the Executive Director will also complete at least two (2) hours of training each month. Compliance in this area will be monitored by the Human Resources Department. Additionally the Executive Director will maintain a aggregate, monthly training record, authenticated by a member of the Human Resources Department each month as evidence of compliance. [In training year 1/1/17 to 12/31/17, CEO completed 5.75 and so far in training year 1/1/18 to 12/31/18, CEO completed 23 hours of training. Documentation of audits of training records by the HR Department shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.141(c)(10)Individual #1's physical examination completed 3/2/17 did not address communicable disease; therefore, compliance could not be measured.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The physical exam form was redone by the Beacon Light Adult Residential Services (BLARS) Nurse Manager to address if the client is free from communicable diseases. This form will be sent with the client to their yearly physical; subsequently completed and signed by the physician. A member of the Nursing staff will insure that form is completed correctly and if not will work with the physician¿s office to see that if is completed correctly. This area will be monitored for compliance by the BLARS Nurse Manager and the Program Specialist. [On 2/1/18, Individual #1 had a physical examination competed to include individual is free from communicable diseases. Immediately, the CEO shall educate the Nurse Manager and the program specialist as to the required information in individuals' physical examinations as per 6400.141(c)1-15. Documentation of the training shall be kept. Upon completion of individuals' physical examinations the Nurse Manager and the program specialist shall audit individuals' physical examinations to ensure all required information is present and there are not any required areas left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.141(c)(11)Individual #1's physical examination completed 3/2/17 did not include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. (Repeated Violation-12/21/16, et al)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. The physical exam form was redone by the Beacon Light Adult Residential Services (BLARS) Nurse Manager to address the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals. This form will be sent with the client to their yearly physical; subsequently completed and signed by the physician. A member of the Nursing staff will insure that form is completed correctly and if not will work with the physician¿s office to see that if is completed correctly. This area will be monitored for compliance by the BLARS Nurse Manager and the Program Specialist. Additionally, this area will be checked during regularly scheduled record reviews. [On 2/1/18, Individual #1 had a physical examination competed to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Immediately, the CEO shall educate the Nurse Manager and the program specialist as to the required information in individuals' physical examinations as per 6400.141(c)1-15. Documentation of the training shall be kept. Upon completion of individuals' physical examinations the Nurse Manager and the program specialist shall audit individuals' physical examinations to ensure all required information is present and there are not any required areas left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.141(c)(12)Individual #1's physical examination completed 3/2/17 did not include: Physical limitations of the individual. (Repeated Violation-12/21/16, et al)The physical examination shall include: Physical limitations of the individual. The physical exam form was redone by the Beacon Light Adult Residential Services (BLARS) Nurse Manager to address the physical limitations. This form will be sent with the client to their yearly physical; subsequently completed and signed by the physician. A member of the Nursing staff will insure that form is completed correctly and if not will work with the physician¿s office to see that if is completed correctly. This area will be monitored for compliance by the BLARS Nurse Manager and the Program Specialist. Additionally, this area will be checked during regularly scheduled record reviews. [On 2/1/18, Individual #1 had a physical examination competed to include physical limitations of the individual. Immediately, the CEO shall educate the Nurse Manager and the program specialist as to the required information in individuals' physical examinations as per 6400.141(c)1-15. Documentation of the training shall be kept. Upon completion of individuals' physical examinations the Nurse Manager and the program specialist shall audit individuals' physical examinations to ensure all required information is present and there are not any required areas left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.141(c)(14)Individual #1's physical examination completed 3/2/17 did not include: Medical information pertinent to diagnosis and treatment in case of an emergency. (Repeated Violation-12/21/16, et al)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical exam form was redone by the Beacon Light Adult Residential Services (BLARS) Nurse Manager to address the Medical information pertinent to diagnosis and treatment in case of an emergency. This form will be sent with the client to their yearly physical; subsequently completed and signed by the physician. A member of the Nursing staff will insure that form is completed correctly and if not will work with the physician¿s office to see that if is completed correctly. This area will be monitored for compliance by the BLARS Nurse Manager and the Program Specialist. Additionally, this area will be checked during regularly scheduled record reviews. [On 2/1/18, Individual #1 had a physical examination competed to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the CEO shall educate the Nurse Manager and the program specialist as to the required information in individuals' physical examinations as per 6400.141(c)1-15. Documentation of the training shall be kept. Upon completion of individuals' physical examinations the Nurse Manager and the program specialist shall audit individuals' physical examinations to ensure all required information is present and there are not any required areas left blank. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.151(a)Direct Service Worker #2, date of hire 10/23/17, had a physical examination completed 11/3/17. Direct Service Worker #3, date of hire 5/27/14, had a physical examination completed 12/2/14 then again 12/20/16. 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. Effective immediately, direct care workers will be notified of the need for their physicals in the 23rd month of the 24 month cycle so that the physical can be scheduled and the TB test can be read before the two year time frame expires. This new process will be monitored by the Human Resources Department as well as during monthly checks on when physicals are due by the Program Specialist. As evidence of compliance in this area the Program Specialist will maintain monitoring checks documentation in his office. [Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of staff persons physical examinations including Tuberculin skin testing. Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for ensuring timely completion of their responsibilities. At least quarterly for 1 year, the CEO or designee shall audit the tracking system and all staff persons' two most physical examinations to ensure timely completion. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.151(c)(2)Direct Service Worker #2, date of hire 10/23/17, had a Tuberculin skin testing completed 11/6/17. Direct Service Worker #3 had a Tuberculin skin testing completed 12/4/14 and then again 12/22/16. 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. Direct care workers will not be able to start working in the waiver program until the program has been notified by Human Resources that their physical was completed and that the TB test showed that the individual was free from any communicable diseases. The Human Resources Department and the Program Specialist will be responsible for monitoring this area. Additionally, the Program Specialist will maintain in his office documentation of each employee¿s compliance with the TB process and the respective due dates for each employee¿s TB tests moving forward. [Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of staff persons physical examinations including Tuberculin skin testing. At least quarterly for 1 year, the CEO shall audit the tracking system and staff persons' two most physical examinations to ensure timely completion. Documentation of audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
6400.163(c)Individual #2's psychiatric medication review completed 11/15/17 did not include the medications being prescribed, the reasons for prescribing the medications, the need to continue the medications and the necessary dosages of the medications. Individual #2's psychiatric medication reviews completed 8/24/17, 5/11/17 and 2/9/17 did not include the reasons for prescribing 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.A new form was developed by the Beacon Light Adult Residential Nurse Manager and the Program Specialist which will be used for all psychiatric medication checks moving forward. This form will include the name of the resident, the name of the medications, the dosage of the medications, the reason for the medication, the need to continue the medication and physician signature/date. This form will be given to the doctor by the nursing staff and will be maintained in the nursing files/client record. The BLARS Nurse Managers will be responsible for monitoring this area for compliance. Additionally, this area will be checked during regularly scheduled record reviews. [Immediately, the CEO shall educate the Nurse Managers and Program specialist as to what is required in psychiatric medication reviews. Documentation of training shall be kept. Upon completion the Nurse Manager and program specialist shall audit the psychiatric medication documentation to ensure all required information is included and will immediately obtain missing information from the completing physician. Documentation of all audits shall be kept. (AS 2/8/18)] 02/01/2018 Implemented
SIN-00105360 Renewal 12/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin test completed 7/3/14 and then again on 7/21/16.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. All clients in the programs affected by this regulation will now be on a 23 month schedule for TB tests to insure that they all fall within the 24 month time frame. Any test outside of this time frame will have a nursing progress note with an explanation of the extenuating circumstances (vaccine not available, client illness, etc). To ensure ongoing compliance (effective immediately) during monthly record review meetings, this area will be tracked for all individuals affected by this regulation. The Nurse Manager will be responsible for monitoring this area. [Immediately and upon completion a designated nursing staff person shall review all individuals' physical examinations to ensure all required information is included and will obtain missing information as needed. (AS 1/19/17)] 01/15/2017 Implemented
6400.142(a)Individual #2's most recent dental examination was completed 9/10/15.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Client #2 has a dental exam scheduled for 3/13/17. All of the clients in the program will now be on an 11 month schedule for appointments to insure that all of their dental appointments fall within the 12 month time frame. Any appointment outside of this time frame will have a nursing progress note with an explanation of the extenuating circumstances (Doctor reschedules, client illness, etc). To ensure ongoing compliance (effective immediately) during monthly record review meetings, this area will be tracked for all individuals affected by this regulation. The Nurse Manager will be responsible for monitoring this area.[Immediately, designated nursing staff shall review all individuals dental examination to ensure timely completion. Documentation of aforementioned reviews and tracking shall be kept. (AS 1/19/17)] 01/15/2017 Implemented
6400.163(c)Individual #2 had a psychiatric medication review completed 7/21/16 and then again on 11/10/16. 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 Nursing Manager will coordinate with the scheduler of all the psychiatric appointments to insure that they will fall within the three month time frame. Any appointment outside of this time frame will have a nursing progress note with an explanation of the extenuating circumstances (Doctor reschedules, client illness, etc). The Nurse Manager and the Director of Specialty Programs will check all individuals who currently are required to have psychiatric appointments and will ensure that all appointments are scheduled within the appropriate time lines. To ensure ongoing compliance (effective immediately) during monthly record review meetings, this area will be tracked for all individuals affected by this regulation.[Documentation of aforementioned reviews and tracking shall be kept. (AS 1/19/17)] 01/15/2017 Implemented
SIN-00086589 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)The Rights for Individual #2 were signed by the Guardian on 2/21/14 and 3/20/15. The agency notified the Guardian on 1/30/15.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. A new form has been developed for the Bill of Rights which includes a signature area. Effective immediately, the individual¿s legal guardian will sign off on the Bill of Rights statements. This will verify that parents/guardians have received and read the Bill of Rights. All consents and supporting documentation/information is sent out to legal guardians the first week of January each year. This information will also be sent out with ¿receipt requested¿ so that we can track when the parents and guardians receive these and will be able to follow up with the them if not returned to us in a timely fashion. This new process will be effective 1/15/16. 12/24/2015 Implemented
6400.67(b)The linoleum tiles between the enclosed back porch and the kitchen were delaminating; posing a tripping hazard.Floors, walls, ceilings and other surfaces shall be free of hazards.the linoleum tiles between the kitchen and the back door at 102 Williams Street have been repaired by the maintenance department and pictures will be forwarded in a separate attachment as evidence of completion. These repairs were completed on 11/20/15. In an effort to monitor life safety and other programmatic issues, a form has been completed which will be completed two time per month by the group home managers that will include emergency numbers being posted, any internal or external maintenance issues or concerns, and vehicle issues or concerns. Upon completion, these forms, they will be turned into the Program Specialist for monitoring and storage. The maintenance department will be notified based on these inspections to insure timely repair of listed issues. This process will be fully implemented by 1/15/16. 12/24/2015 Implemented
6400.80(a)The third step from the bottom of the outside steps at the front entrance of the home had an 18 inch long by 3 inch wide crack; posing a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. The porch steps at 102 Williams Street have been repaired by the maintenance department and pictures will be forwarded in a separate attachment as evidence of completion. These repairs were completed on 11/20/15. In an effort to monitor life safety and other programmatic issues, a form has been developed which will be completed two time per month by the group home managers that will include emergency numbers being posted, any internal or external maintenance issues or concerns, and vehicle issues or concerns. Upon completion, these forms, they will be turned into the Program Specialist for monitoring and storage. The maintenance department will be notified based on these inspections to insure timely repair of listed issues. This process will be fully implemented by 1/15/16. 12/24/2015 Implemented
6400.112(c)The fire drill records for 1/5/15 and 3/10/15 did not include information on what exit was used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Director of IDD will conduct a training for all staff on the proper protocols for running fire drills as well directives/reminders on how to fill out the fire drill form correctly. During these trainings the Director of IDD will also stress the need to make sure that alternate exits are used as well as documenting which exits are used on the fire drill form. These trainings will be conducted by 1/15/16. The Human Resources department is responsible for monitoring this area as they track fire drills agency-wide. 12/24/2015 Implemented
6400.181(e)(12)The assessment for individual # 1, dated 11/5/15, did not include any recommendations for programming. The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Program Specialist will begin adding additional information on the assessment to include progress made from the previous year and include any recommendations for future programming. We will also make any Recommendations for training will also be added if needed. As a method to monitor this area moving forward, these assessments will be reviewed and signed off on by either the Director of IDD or the program¿s Licensed Psychologist and then placed in their record. This process will be formalized to include all individuals in the program. This area will be completed by 1/15/16. 12/24/2015 Implemented
6400.181(f)The assessment for Individual #1, dated 11/5/15 was not sent to the entire team. The assessment for Individual #2, dated 7/20/15 was not sent to the entire team. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Each annual assessment (effective immediately) will now include information that details that the assessment was sent to the plan team members. The Program Specialist will be responsible for forwarding this assessment and documentation that verifies the information was forwarded. As added verification, the email or fax cover sheet that was used in the transfer of the materials will be kept as verification of the sent correspondence. All of this information will be stored in the permanent record. 12/24/2015 Implemented
6400.186(e)The program specialist did not notify the plan team members of the option to decline ISP review documentation for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The program specialist will resend the option to decline ISP review documentation to all members of the team and this will done by 1/15/16. Additionally, the option to decline ISP review documentation will be part of the annual consent package so that this will become a yearly part of the individual record. The Program Specialist will be responsible for making sure this declination is done for each ISP review. 12/24/2015 Implemented
SIN-00072309 Unannounced Monitoring 11/18/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's certificate expired on 10/1/14; however, the self assessment of the home was completed on 10/16/14.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self- assessment for the waiver homes will now be completed each year during the first week of June to insure that this will be done within the 3 to 6 month time frame that is required. This will start in June of 2015. Effective Date 1/1/15 12/19/2014 Implemented
6400.31(b)The "Rights" form, signed by Individual #1 on 2/23/14, did not state the full rights per regulations 33(b) regarding the participation in research projects, 33(h) regarding the use of a telephone, 33(j) regarding voting, and 33(l) regarding the right to be free from excessive medication. Per 6400.33(b), "An individual may not be required to participate in research projects." Per 6400.33(h), "An individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary." Per 6400.33(j), "An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections." Per 6400.33(l), "An individual has the right to be free from excessive medication." Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The bill of rights will be amended to include the full rights regarding the participation in research projects, the use of a telephone, be free from excessive medication, and that an individual will be informed of his right to vote. We will have all the clients sign off on the new bill of rights forms and these will be included in the clients record . This will also be updated on a yearly basis when the individuals or their guardians update their consent packages. Effective Date 1/15/15. 12/19/2014 Implemented
6400.46(c)Staff person #1, the CEO of the program, had 11.75 hours of training during 2013. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.Effective 1/1/15, the Ramsbottom Executive Director will obtain at least 24 hours of training relevant to human services or administration annually. The Executive Director will enroll in the January 2015 training schedule as well as take outside trainings which will be used to satisfy the regulatory training requirements. The Executive Director¿s training hours will be monitored by the Human Resources Department and will be documented on a staff fact sheet that is distributed monthly. In subsequent years, the Executive Director will obtain all training hours in the first quarter of each calendar year; this will be documented on the employee¿s staff fact sheet. The Human Resources Department is responsible for monitoring this area for compliance. In addition to the 24 hours of training required for the 2015 training year, the CEO will complete an additional 12.25 hours during the 2015 training year. 12/19/2014 Implemented
6400.112(f)An alternate exit route was not used during fire drills between the months of October 2013 through October 2014.Alternate exit routes shall be used during fire drills. Beginning 1/1/15, all programs of Ramsbottom Center will conduct fire drills using alternative routes for exit. This process will be monitored by the Director of IDD monthly. All fire drill reports are turned to the Director of IDD monthly. The agency's safety committee also monitors this area. 12/19/2014 Implemented
6400.142(a)Individual #1's most recent dental exam was completed on 5/21/13.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 will have a dental exam scheduled at the first available opening by the nursing department. This appointment date will be scheduled asap. [Individual #1 will have a dental exam completed by 2/28/15. The CEO or Program Specialists will audit all individuals records to ensure they contain documentation of a timely dental exam. (CHG 1/22/15) 12/19/2014 Implemented
6400.142(f)Individual #1's record does not include a dental hygiene plan.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Individual #1 will have a dental hygiene plan incorporated into his record by 1/15/15. The Director of Specialty Programs will review all clients in the program to ensure that a dental hygiene plan exists; this will also occur by 1/15/15. The Director of Specialty Programs reviews each dental hygiene plan on a monthly basis and this check is documented in each individual¿s record. Effective date 1/15/15. 12/19/2014 Implemented
6400.181(d)Individual #1's assessment, completed 1/16/14, was not signed and dated by the Program Specialist.The program specialist shall sign and date the assessment. Individual #1¿s completed assessment was signed by the Director of Specialty Programs on. Moving forward each assessment will have a signature line designated for the Program Specialist (Director of Specialty Programs). A form documenting these assessment signatures will be signed off on by the Director of Specialty Programs and placed in the record as evidence that all necessary signatures on assessments are completed. This will occur at the annual ISP review. This process will be initiated beginning 1/1/15. [All current assessments will be reviewed by the CEO or program specialist to ensure that they have beens signed by the person completing the assessment and the program specialist. Going forward, the assessment will be reviewed and signed by the program specialist immediately upon completion of the assessment. (CHG 1/22/15)] 12/19/2014 Implemented
6400.181(e)(1)Individual #1's assessment, completed 1/16/14, did not include functional strengths, needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Individual #1¿s assessment now includes functional strengths, needs, and preferences. These areas in the assessment will be updated yearly and incorporated into each individual¿s annual ISP update. Compliance with this area will be evidenced in each annual ISP update under the functional strengths, needs, and preferences section. Effective date: 1/1/15. [All current assessments will be reviewed by the CEO or program specialist to ensure that they contain all required information including the functional strengths, needs and preferences of the individual. (CHG 1/22/15)] 12/19/2014 Implemented
6400.181(e)(6) Individual #1's assessment, completed 1/16/14, did not include his/her ability to safely use or avoid poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The skills assessment for all individuals will be revised to include a section on the ability to safely use or avoid poisonous materials. All Individuals assessment will be updated to include this area by 1/1/15. Compliance with this area will be evidenced in each annual ISP update under the ability to safely use or avoid poisonous materials section. Effective date: 1/1/15. 12/19/2014 Implemented
6400.181(e)(14)Individual #1's assessment, completed 1/16/14, did not include his/her ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The skills assessment for all individuals will be revised to include a section on the ability to swim. All Individuals assessment will be updated to include this area by 1/1/15. Compliance with this area will be evidenced in each annual ISP update under the water safety section. Effective date: 1/1/15. 12/19/2014 Implemented
6400.181(f)Individual #1's record did not indicate that the assessment, completed 1/16/14, was sent to the treatment team. Repeat Violation 10/2/13.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). At least 30 days prior to the ISP meeting for each individual, the Director of Specialty Programs (Program Specialist) will send a copy of the completed assessments to the Supports Coordinators. This will be documented as evidenced by a copy of the email that was used to send the documents to the SC¿s or a copy of the fax transmission cover sheet. These documents will be filed in the individual¿s record in the ¿correspondence¿ section. Effective date: 1/1/15. 12/19/2014 Implemented
SIN-00051544 Renewal 10/02/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)A prostate examination was not completed for Individual #1 on an annual basis. The most recent prostate exam was completed on 9/10/2012.(9) A prostate examination for men 40 years of age or older. Effective 10/7/13, prostrate exams for all the individuals at the Williams Street waiver program will now be scheduled on an eleven month cycle so that they will happen within the one year time span. If for any reason this cannot happen due to circumstances at the physician¿s office, the nursing staff will place in the client¿s file a progress note that will state that the appointment was scheduled and the reasons on why the appointment did not occur as scheduled. A subsequent appointment will be scheduled at the next earliest date. All appointments will be progress noted and the notes will be placed in the individual¿s file. Jim Carroll, Program Specialist will convey this process change through a formal training with the nursing department and this session will be documented on an ¿On-Campus Training Record.¿ This area will be monitored by the nursing staff and all documentation relating to appointments will be given to Jim Carroll, Program Specialist to file in the individual¿s treatment books. The appointment of Mike Monti which was out of compliance did occur on 10/17/13. [All current physical examinations will be checked by the Program Specialists and Director to ensure that they contain the required regulatory requirements by 12/12/13. The Director will sample ten percent of individual records and audit the contents of those records including physical examinations monthly. Documentation of the monthly audits shall be kept. (CHG 11/12/13)] 10/28/2013 Implemented
6400.168(d)On 10/2/13, there was no documentation to indicate that Staff #1 had completed the medication administration practicum on an annual basis. The most recent training completion date was 3/28/2012.(d) A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Each of the waiver staff receive medication administration training annually. They most recently took the course in February/March of 2013. Unfortunately during the survey the documentation of this course was misplaced/misfiled in the Human Resources department. It has since been found and documentation of the sign in sheets and post course exams have been located. Therefore, there is documentation that indicates that all waiver staff took the medication administration course in February of 2013. Effective immediately, in addition to submitting medication administration coursework documentation to the agency¿s Human Resources Department, Jim Carroll, Program Specialist for the waiver program will also keep a copy in his office as evidence that the course was provided and who participated. Following each medication administration annual training, Jack Golden, Director of IDD will also review all training documentation prior to it being filed in the Program Specialist¿s office. [All testing, practicums and observations will be completed per the requirements of the medication administration training for all staff persons administering medications. All staff records will be audited by the Program Specialists and Director to ensure that they contain a copy of the required documentation for the medication training. (CHG 11/12/13)] 10/28/2013 Implemented
6400.181(f)The annual assessment for Individual #1, dated 11/19/12, was not provided to plan team members at least 30 days prior to the annual ISP meeting. The date of the meeting was 11/19/2012.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Effective 10/7/13, a new process was developed to ensure that all annual assessments are sent to SC at least 30 days prior to the ISP. Immediately following notification of the ISP the Program Specialist (Jim Carroll) will begin the assessment process and will have this documentation completed and ready to send to the SC five days prior to the due date. The Program Specialist will then place in the clients file a copy of the email that was sent to the SC with the completed assessments. This change has already been implemented; on 10/14/13 assessments were sent in to the SC for an ISP that is scheduled to occur on 11/18/13. This procedure will now be the standard for all new assessment completion in the waiver program and will be monitored by Jim Carroll, Program Specialist and Jack Golden, Director of IDD, who will also be given the due date of when the assessments need completed and given a copy of the email of when completed as well. 10/28/2013 Implemented
6400.186(d)The 3-month ISP reviews for Individual #1, dated 8/1/13, 5/14/13, 2/12/13, 11/15/12, and 8/21/12, were not provided to the supports coordinator and plan team members within 30 calendar days after the review dates.(d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program Specialist (Jim Carroll) has now added to the ISP quarterly reviews a check box to indicate when the reviews were sent to the SC as well as team members who have asked for these reviews. This will be done starting with the reviews that are due on 10/30/13. This review will be in the clients file which will verify that these have been sent. The Program Specialist will also place a copy of the email sent to the SC in the file as well. In addition, a cover letter will be sent to the guardians and a copy of this will be placed in the client¿s file. Jim Carroll, Program Specialist will be responsible for implementing this correction and Jack Golden, Director of IDD, will be receiving a copy of these letters and emails to insure that they are being done within 30 days after the reviews are completed. 10/28/2013 Implemented
SIN-00165520 Renewal 11/06/2019 Compliant - Finalized