| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(a) | Individual #1 was informed of the individual's rights on 12/4/15 and then again on 12/22/16. | 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. | The individual¿s rights, Voting Rights, and Grievance Procedures will be reviewed and signed each year with the individuals when their annual assessments are completed. During the audit scheduled for 8/8/17, dates of Rights and assessments will be checked. Resident Managers and Program Specialists will schedule assessments and rights reviews to be completed assuring that each meets the regulatory annual requirement.
Quarterly chart audits- completed one time every three months by house managers to ensure all necessary items are in individual big books and that all forms are completed correctly and thoroughly. Audits are completed at Manager¿s team meetings under the supervision of the Program Specialists and the Program Director. Deficit areas will be identified at the time audits are completed and any missing items/signatures will be completed at that time. [At least quarterly, for 1 year, the CEO or designee shall review a 10% sample of "SLS Record Audit" forms to ensure individuals' are informed of individual rights, timely. (AS 8/10/17)] |
07/31/2017
| Implemented |
| 6400.65 | The bathroom in the basement did not have a window and the mechanical ventilation was not operable. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Ceiling fan was replaced on 6/30/17 by Mark Manson, Maintenance. Mechanical ventilation checks were added to the Program Director Quarterly Checklist and the Maintenance check list to ensure these items are inspected frequently and repairs are made when needed. Any concerns identified via the pre-inspection process can be repaired by the SLS maintenance team.
Program Director and Maintenance team will conduct reviews each quarter of the year. Needed repairs will be reported via electronic work ticket and work will be completed immediately. Residential Managers will be made aware of this concern at the August 8, 2017 Manager¿s meeting and it was added to the pre-Inspection Checklist which manager¿s complete one time each month. |
07/31/2017
| Implemented |
| 6400.106 | The two most recent furnace inspections were completed on 10/30/15 and 11/16/16. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| SLS Maintenance Director has changed vendors and contracted with a new company, Keep Heating. Keep will conduct furnace inspections on October 23, 2017. Maintenance/IT Director will set up electronic tracking by date to ensure that 2018 inspections occur prior to the 2017 dates, maintaining compliance with the 6400 regulations.Who?When?PPR?Inspections will be scheduled and conducted by Maintenance Director and Keep Heating administration to occur two times in each home, each calendar year. Copies of Furnace System check invoices will be forwarded to Program Director from Maintenance Director for inclusion with annual inspection documents. Program Director and Maintenance Director met on July 28, 2017 to review 6400 regulations to clarify expectations for our residential sites so maintenance has an increased understanding of the requirements. |
08/31/2017
| Implemented |
| 6400.164(a) | Toviaz 8 mg, take 1 tablet by mouth every morning prescribed for Individual #1 was not initialed as administered on 6/2/17 at 8:00AM. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Immediately- Managers will review the Steps/Process for medication administration with all staff and include the need to prioritize staff documenting the administration of medication appropriately and immediately. All will review the procedure for reporting blanks on the MAR¿s and how to determine whether a documentation error or medication error has occurred, along with the proper follow-up action for both. This will be completed by the end of August, 2017 at house team meetings. All MAR Discrepancies will be reported to House Manager immediately.
Resident Managers will continue to review/monitor MAR¿s weekly. Program Specialist will inspect MAR¿s to confirm the MAR¿s were reviewed by the house manager and to see if any medication errors were noted and resolved. This inspection of the MAR¿s by the Program Specialist will occur at least every other week for eight weeks, and at least monthly thereafter. Managers will follow up with staff regarding any concerns in accordance with the agency disciplinary process immediately upon discovery.
Resident Managers will continue to review/monitor MAR¿s weekly, on an ongoing basis, to ensure that all entries are completed and provided in a timely manner. Managers will follow up with staff regarding any concerns following the agency disciplinary process. All completed MAR¿s are turned in to the HealthCare Supervisor at the end of each month for review. Healthcare Supervisor reviews them for completion at the time they are turned in. Program Specialists will oversee MAR reviews by Resident Managers to ensure they are completed. |
07/31/2017
| Implemented |
| 6400.213(1)(i) | Individual#1's record did not include a photograph that was dated. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Program Specialists will review this process with Residential managers at the next manager¿s meeting scheduled for August 8, 2017. Managers will be instructed to take an updated photograph of each individual assigned to their homes in December of each year. Program Specialists will make sure to complete updated forms the following year and follow-up each year on or before the date the previous year. All photographs will be labeled with the individual¿s name and the date the photo was taken and filed in Individual big books.Who?Managers will take an updated photograph of each individual each year in December. Program Specialists will review charts when audits are completed to ensure all items are filed and complete. Program Specialists will make sure anything missing from individual charts is replaced if audit indicates something is missing. Managers will continue to conduct quarterly chart audits to ensure necessary paperwork is filed and complete.
Resident Managers will make a list of the dates that individual assessments and subsequent photos were taken and send it to Program Specialists. Program Specialists will ensure that all information is updated in individual records at this time. [Immediately, the program specialist or designee shall update Individual #1's record to include a current, dated photograph. Within 60 days of receipt of the plan of correction, the program specialist will audit all individuals' records to ensure all personal information is included. Documentation of audits shall be kept. At least quarterly, for 1 year, the CEO or designee shall review a 10% sample of "SLS Record Audit" forms to ensure all required personal information is included in individuals' records. (AS 8/10/17)](AS 8/10/17) |
07/31/2017
| Implemented |