| 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 |
| 6400.46(i) | Direct Service Worker #1 completed First Aid training on 1/22/14 and then again on 2/24/16. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | A training committee was recently formed, in August of 2016 to improve our tracking system to ensure that all staff are in compliance with completion of annual mandatory/required trainings.
We will utilize the HR software, a web-based HR component to track staff hours and course completion. The system has an alert component built into it which will notify all staff of their upcoming trainings and expiration dates. Alerts are automatically sent to the immediate supervisor. Immediate supervisor will monitor to ensure required trainings are scheduled and completed. Training records will be turned in and filed at the main office. Records will be monitored monthly by the Front Office secretary. Human Resource department will follow up on any issues or concerns regarding staff training hours.
All staff will be provided with their own list of required trainings for the year with the dates they are due to complete them. Any staff who fails to meet the expiration dates, will be suspended immediately and will not be permitted to work until course requirements are satisfied. [Within 60 days of the receipt of the plan of correction and at least quarterly thereafter, the program director shall review the aforementioned process to ensure procedures are being followed and required trainings are completed, timely. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.64(a) | The nonslip bathtub mat was stained with a black substance that appeared to be mildew. | Clean and sanitary conditions shall be maintained in the home. | Checking bath mats to ensure that they are mold free has been added to all house third shift checklists along with the bathroom/shower checks. Third shift staff will continue to complete nightly checks of the homes and Residential managers will review checklists at least one time each week and continue to complete the pre-inspection checklists one time per month.
All individuals will be trained on general cleaning maintenance during the month of October 2016, as it pertains to health and safety concerns in the homes. The house meetings will be the forum in which the training will occur during the month of October 2016. All documentation of training including sign-in sheets will be kept on file in the Program Director¿s office. [Trainings will include any identified or reported unsanitary conditions will be corrected immediately by the staff person identifying the situation or a designated staff person. Within 30 days of receipt of the plan of correction a designated staff person will monitor each home at least monthly to ensure sanitary conditions are maintained to include checking bedrooms and bathrooms. Documentation of trainings and home monitoring will be kept. (AS 11/8/16) |
09/28/2016
| Implemented |
| 6400.76(a) | The handle of the soap dispenser of washing machine was missing. The center knob used to light the burners of the stove was missing leaving a metal piece approximately 1/2" in length protruding from the stove. | Furniture and equipment shall be nonhazardous, clean and sturdy. | SLS has developed an online work request that requires prompt response from the maintenance department for any needed repairs or replacements. All staff have access to this and all were trained by IT on how to use the system. The system also sends notification to the sender when the job has been completed. [Repairs were made to the washing machine and stove. At least monthly, a designated staff person shall complete an onsite walk through of all community homes to ensure furniture and equipment are nonhazardous, clean and sturdy and aforementioned procedures are being implemented. Any furniture and equipment not clean or posing a hazard shall immediately cleaned/repaired. If unable to make immediate repairs the item will be removed from service until repairs are made. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 9/23/15, did not include health maintenance needs, medication regimen and the need for blood work. | 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. | An SLS physical form has been redesigned to include this information. Copies of SLS physical form are provided to the Supports Coordinator by Program Specialists prior to admission along with an instruction sheet for completion. The physical form must be filled out in its entirety, including all of the mandated information. Before agreeing to admission, the intake packet will be reviewed by the administrative team (Executive Director, Program Director, Medical Director, and Program Specialist (if assigned)) to approving the placement. [Individual #1 had a physical examination completed on 9/27/16 to include health maintenance needs, medication regimen, need for blood work, physical limitations, medical information pertinent to diagnosis and treatment in case of an emergency and special diet instructions. Immediately, the administrative team will review all physical examinations forms to ensure all required information is included and the examination is completed timely. The aforementioned team shall develop and implement policies and procedures to ensure missing information is obtained prior to being entered into the record. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed 9/23/15, did not include physical limitations. | The physical examination shall include: Physical limitations of the individual. | An SLS physical form has been redesigned to include this information. Copies of SLS physical form are provided to the Supports Coordinator by Program Specialists prior to admission along with an instruction sheet for completion. The physical form must be filled out in its entirety, including all of the mandated information. Before agreeing to admission, the intake packet will be reviewed by the administrative team (Executive Director, Program Director, Medical Director, and Program Specialist (if assigned)) to approving the placement.[Individual #1 had a physical examination completed on 9/27/16 to include health maintenance needs, medication regimen, need for blood work, physical limitations, medical information pertinent to diagnosis and treatment in case of an emergency and special diet instructions. Immediately the administrative team will review all physical examination forms to ensure all required information is included and the examination is completed timely. The aforementioned team shall develop and implement policies and procedures to ensure missing information is obtained prior to being entered into the record. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 9/23/15, did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | An SLS physical form has been redesigned to include this information. Copies of SLS physical form are provided to the Supports Coordinator by Program Specialists prior to admission along with an instruction sheet for completion. The physical form must be filled out in its entirety, including all of the mandated information. Before agreeing to admission, the intake packet will be reviewed by the administrative team (Executive Director, Program Director, Medical Director, and Program Specialist (if assigned)) to approving the placement. [Individual #1 had a physical examination completed on 9/27/16 to include health maintenance needs, medication regimen, need for blood work, physical limitations, medical information pertinent to diagnosis and treatment in case of an emergency and special diet instructions. Immediately, the administrative team will review all physical examination forms to ensure all required information is included and examinations are completed timely. The aforementioned team shall develop and implement policies and procedures to ensure missing information is obtained prior to being entered into the record. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination, completed 9/23/15, did not include special diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | An SLS physical form has been redesigned to include this information. Copies of SLS physical form are provided to the Supports Coordinator by Program Specialists prior to admission along with an instruction sheet for completion. The physical form must be filled out in its entirety, including all of the mandated information. Before agreeing to admission, the intake packet will be reviewed by the administrative team (Executive Director, Program Director, Medical Director, and Program Specialist (if assigned)) to approving the placement. [Individual #1 had a physical examination completed on 9/27/16 to include health maintenance needs, medication regimen, need for blood work, physical limitations, medical information pertinent to diagnosis and treatment in case of an emergency and special diet instructions. Immediately the administrative team will review all physical examination forms to ensure all required information is included and examinations are completed timely. The aforementioned team shall develop and implement policies and procedures to ensure missing information is obtained prior to being entered into the record. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.186(b) | Individual #1's ISP review, end dated 4/27/16, was not signed and dated by the program specialist. | 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 review dated 4/27/16 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 |
| 6400.213(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 |
| 6400.216(a) | A open box containing a "face sheet", emergency medical information, signed individual rights and other personal information regarding Individual #2, who no longer resides at the home was unlocked and unattended on a shelf in the basement of the home. | An individual's records shall be kept locked when unattended.
| All managers were instructed to gather old records and documents for individuals no longer residing in the home. Old records have been collected and are currently being stored at the main office in the chart room. Old records will be kept for 10 years after the discharge and/or death of an individual. The agency policy on Record retention was modified to direct managers to transfer records from discharged or deceased individuals to the main office for storage by the end of the succeeding month of the individual¿s departure.[At least monthly, a designated staff person shall complete an onsite walk through of all community homes to ensure all individual's records are kept locked when unattended and aforementioned policy and procedures are being implemented. All staff will be trained on revised record retention policy. Documentation of training and home monitoring shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |