| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certificate of compliance expires on 8/10/16. The agency completed a self-assessment of the home on 6/3/16. | 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.
| Upon receipt of the certificate of compliance, Program Director will develop a timeline of tasks to be completed and share with all program staff via manager¿s and assistant manager¿s meetings and email alerts. Program Director will set deadlines for Program Specialists, medical personnel and HR to complete pre-inspection checklists (LICENSING INSPECTION INSTRUMENT SCORESHEET.) The Program Director will track completion of Pre-Inspection checklists and will file in PD office so they will be available to inspectors when they arrive. All Pre Inspection checklists will be completed 3-6 months prior to expiration listed on certificate of compliance. Program Director will assign Program Specialists group homes to inspect[Immediately, the CEO will review the most recent Certificate of Compliance to determine the date the current license expires an develop and implement a tracking system to ensure the agency completed self-assessment 3 to 6 months prior to the expiration date of the Certificate of Compliance. Upon completion of the self-assessment, the CEO will review and cross reference with the expiration date of the Certificate of Compliance to ensure timely completion. Within 30 days of receipt of the plan of correction, the CEO will train all staff responsible of completing the self-assessments on the tracking system to ensure timely completion. Documentation of training shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.112(d) | The fire drill held on 10/20/15 had an evacuation time of 3 minutes and 1 second. The home does not have an extended evacuation time specified in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Individuals receive Fire safety training upon admission and annually thereafter from a Program Specialist. Monthly Fire Drills serve as an ongoing assessment tool to determine if individuals are able to evacuate safely within the 2 ½ minute mark. If an individual fails to evacuate within the 2 ½ minutes allotted the team will work to determine the reason for the change and make adjustments to accommodate the individual¿s changing needs. The individual will be reeducated about fire safety if deemed necessary and the house staff will be trained on the changes in need for the individual. [(If needed and appropriate, the agency will work with the local Fire Department and secure an extended time for drills.)NOT ACCEPTABLE (AS 11/8/16)] The results of the ongoing assessment and each individual¿s needs are to be summarized on the evacuation plan for each house and within each individual¿s Support Plan completed by the Program Specialist. This information will be documented on the Fire Drill Report Form and turned in to Program Specialists as completed.
All agency staff receive fire safety training as part of orientation and annually thereafter. Resident Managers train new employees during in-house orientation on the evacuation procedures for the house, including the individual¿s abilities and need for help as well as the fire system specific to the site. When assigning staff to complete a fire drill they will be provided with guidelines/procedures to complete the drill, the most recent evacuation plan for the site and the procedure for the fire system check for the site. [Fire drills conducted between May, 2016 and August 30, 2016 were completed within the required 2 1/2 minutes. Within 30 days of receipt of the plan of correction, the program specialist(s) shall assess as per regulation 6400.181(e)(8) and train staff in all individuals' ability to evacuate in the event of a fire and identify specific assistance needed. Documentation of training shall be kept. Within 90 days of receipt of the plan of correction, the program specialist(s) shall observe a fire drill at each community home to ensure fire drills are conducted as required including all individuals evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert and documentation is kept as required. Immediately, and monthly for 3 months and then at least quarterly thereafter, the Program director will review a 25% sample of fire drill records to ensure fire drills are conducted and documented as required. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.112(f) | The fire drills completed between 6/21/15 and 6/6/16 used the front door as an exit. | Alternate exit routes shall be used during fire drills. | Part of our Fire Safety Policy states that each home will have unannounced fire drills and fire system checks on a monthly basis. Fire Drills are to be held on different days, at different times, using different hypothetical locations and exit routes as determined by residential managers. Residential managers will track this on a monthly basis to avoid repeat locations, times, exit routes, day of week, etc. From this point forward, each house will have a ¿fire barrier¿ that will signal where the fire is and one that will provide a visual barrier for our residents so that they know that the exit is blocked and they will need to find another way out of the building. Program Specialists will assure all individuals living there will be educated so that they understand they cannot `pass through¿ the barrier. The barrier will be portable so that it can be moved to block the doors that are targeted for each month. All houses will alternate which exit is used so that the individuals are comfortable and able to exit the home effectively.[Fire drills conducted between May, 2016 and August 30, 2016 were completed using alternating exits. Within 3 months of receipt of the plan of correction, the program specialist(s) shall observe a fire drill at each community home to ensure fire drills are conducted as required including alternating exits. Within 30 days of receipt of the plan of correction and at least quarterly for 1 year, all staff responsible for conducting fire drill shall be trained in requirements of fire drills as per 6400.112 (a)-(i). Documentation of trainings shall be kept. Immediately, then monthly for 3 months and then at least quarterly thereafter, the Program director will review a 25% sample of fire drill records to ensure fire drills are conducted and documented as required. Documentation of reviews shall be kept. (AS 11/8/16) |
09/28/2016
| Implemented |
| 6400.141(c)(7) | Individual #1, date of birth 4/11/63, admitted on 9/14/15 had a gynecological examination completed on 10/26/15. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Supports Coordinator will arrange pre-admission medical care and refusals will be documented by physician. In the event of a refusal, SC will then document counseling/education with the individual. This will be included in the admission paperwork and kept in the client record. SLS will schedule subsequent attempts at exams. (physical must be completed.) Program Specialists will complete desensitization plans to address the underlying cause of the refusal. [Immediately, the Program Director shall develop a tracking system to ensure physical examinations are completed within the required timeframes. At least quarterly the Program Director will review a 25% sample of physical examination documentation including gynecological examinations to ensure timely completion and completion in its entirety. Documentation of reviews shall be kept. (AS 10/7/16)] |
09/28/2016
| Implemented |
| 6400.141(c)(8) | Individual #1, date of birth 4/11/63, admitted on 9/14/15 had a mammogram completed on 11/20/15. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Supports Coordinator will arrange pre-admission medical care and refusals will be documented by physician. In the event of a refusal, SC will then document counseling/education with the individual. This will be included in the admission paperwork and kept in the client record. SLS will schedule subsequent attempts at exams. (physical must be completed.) Program Specialists will complete desensitization plans to address the underlying cause of the refusal.[Immediately, the Program Director shall develop a tracking system to ensure physical examinations are completed within the required timeframes. At least quarterly the Program Director will review a 25%sample of physical examinations including mammogram to ensure timely completion and completion in its entirety. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.186(b) | Individual #1 did not sign and date the ISP review with an end date of 11/2/15. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Upon completion of the quarterly report, the PS signs the report and meets with the individual to review it. At that time, the individual signs the report. If the client is not available, the house manager may be asked to review the report with the individual and to have them sign the report. This is recorded on the ISP Quarterly Review For Time Frame form. A copy of this signed form is sent to all team members that request a copy. This will be added to our Pre-Inspection Checklists so that it is included in our audit process. [Individual #1 signed and dated ISP reviews 1/28/16, 4/27/16, 7/26/16 and the program specialist provided the reviews to all plan team members. Program specialist shall sign and date all ISP review upon review with the individual. Immediately and at least quarterly thereafter, the Program director shall review a 25% sample of ISP reviews to ensure the program specialist and individual sign and date the ISP review. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.186(d) | The program specialist did not provide Individual #1's ISP review with an end date of 11/2/15 to the plan team members. | 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. | After securing internal signatures on the ISP Quarterly Review For Time Frame form, the report is sent to the team members who requested a copy, including the Supports Coordinator. Dates that the reports are sent are documented on the back of the form. Program Specialists will document and re-check all forms for signatures and dates before filing in Individual Big Books. Program Specialists maintain a copy for their files at the main office. This will be added to our Pre-Inspection Checklists so that it is included in our audit process. Quarterly chart audits will ensure compliance and documentation.[Individual #1 signed and dated ISP reviews 1/28/16, 4/27/16, 7/26/16 and the program specialist provided the reviews to all plan team members. Immediately, the program specialist shall sign and date all of the ISP review upon review with the individual. The program specialist will audit all individuals' records to include ISP, invitation letter, and other documentation to ensure all plan team members are provided the ISP reviews as required. Correspondence documentation of ISP review being provided to plan team members shall be kept and a 25% sample shall be reviewed by the Program director to ensure all plan team members are provide ISP reviews as required. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks. | 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. | All staff were retrained in completing agency forms. A memo clarifying that there can be no blanks on any client paperwork was sent out to all staff via e-mail dated 7/17/16 from the Program Director and the executive Director. The staff were directed that if there is no answer to put none known, N/A or to line out and initial but to never leave a line blank. The Program Director has developed an internal chart audit process to provide chart review ensuring all information is complete, relevant and accurate. Chart audits will be completed quarterly for each individual in our residential homes. Any information in individual records that is incomplete will be sent to Program Specialists for completion. Program Director lead audit process and will have residential managers participate in the audit process quarterly. Copies of audit record will be stored in individual records as well as maintained by Program Director's assistant.[Individual #1's record was updated to include identifying marks. Immediately and at least quarterly thereafter, the Program Director shall review a 25% sample of records to ensure all personal information is included including identifying marks. Documentation of all record reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |