Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(d)(1) | Individual #1 had a $15 Subway gift card and a $15 McDonalds gift card. Both gift cards were not logged or tracked on the financial log. | 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. | Regulation 6400.22(d)(1) was reviewed with the Program Manager and House Managers on7/19/2016 by the Assistant Director (Attachment #50) Gift card ledgers are now being documented for any cards or gift certificates the individual may have. Gift card ledgers for individual #1 are attached (Attachment #51). Program Manager will do monthly reviews of all financial transactions. |
07/19/2016
| Implemented |
6400.44(b)(1) | Individual #1's 1/15/16 assessment was completed by Staff #1. Staff #1 is a house manager, not a program specialist. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | Regulation 6400.(b)(1) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #49). Individual #1 was re-assessed on 7/15/2016 by the Program Manager (Program Specialist) (Attachment #15). The Program Manager will ensure that the assessments are completed by himself with input from the House Manager and DSP's involved. |
07/19/2016
| Implemented |
6400.46(e) | REPEATED VIOLATION - 2/17/15 Staff #2 was hired on 5/26/16 and was not trained in intellectual and developmental disabilities, normalization, and program planning. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Regulation 6400.46(e) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #48). The Program Manager will ensure that all newly hired staff attend the full 3 day new hire orientation or complete the entire on-line training to include intellectual and developmental disabilities, normalization and program planning. The Assistant Director will review all training documentation with the first 30 days of employment to ensure compliance. The training sign off for staff #2 are included (Attachment #49). |
07/19/2016
| Implemented |
6400.112(c) | REPEATED VIOLATION - 2/17/15 The fire drill logs from 11/16/15 to 6/2/16 did not include whether or not the smoke detectors were operative. | 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. | Regulation 6400.112(c) was reviewed with the Program Manager and House Managers by the Assistant Director on 7/19/2016 (Attachment #46). Fire Drill logs for July and August were completed correctly to include whether or not the smoke detectors were operative (Attachment #47). The Program Manager will monitor fire drill logs monthly to ensure compliance. The Assistant Director will review a random sampling of the fire drill logs throughout the year to ensure on-going compliance. |
07/19/2016
| Implemented |
6400.144 | Individual #1 was prescribed 50mg of Zoloft to be administered at 8am. On 3/29/16, a Zoloft pill was found in Individual #1's dress. The pharmacist authorized an hour late administration of Zoloft. The medication was administered at 9:45am. On 8/16/15, Lactulose was not available at the home for Individual #1 to receive his/her 8AM dose. Individual #2 required a hospital bed. According to staff in the home, the bed has been broken for at least a month. There was a sign hung on the wall next to the bed that stated the bed shouldn't be plugged in because it could overheat and be a fire hazard. On 8/21/15, Individual #1's physician recommended position changes due to a decubitus ulcer on Individual #1's buttocks. Position changes have not occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Regulation 6400.144 was reviewed with the Program Manager and the House Managers on 7/19/2016 by the Assistant Director (Attachment #45). The Program Manager will ensure that all health services that are planned or prescribed for the individual shall be arranged for and provided. The Assistant Director will review a random sampling of planned/prescribed health services to ensure they are arranged and provided for to ensure on-going compliance. |
07/19/2016
| Implemented |
6400.145(1) | The emergency medical plan did not include the location of the hospital to be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Regulation 6400.145(1) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #43). The emergency medical plan was updated to include the hospital to be used in an emergency (Attachment #44). The CHS Program Manager is responsible for ensuring the plan is posted in the home and will monitor monthly to ensure on-going compliance. |
07/19/2016
| Implemented |
6400.162(a) | REPEATED VIOLATION - 2/17/15 Individual #1's Tylenol had two different medication labels. One label indicated the medication should be given every 6 hours for pain for up to 10 days. The other label indicated Tylenol should be administered every 4 hours. The medication label for Miralax stated to give every 2-3 days and the medication administration record indicated to administer Miralax every 2 days. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Regulation 6400.162(a) was reviewed with the Program Manager and House Manager on 7/19/2016 by the Assistant Director (Attachment #40). House Manager had the doctor discontinue the prescription for Tylenol every 6 hours for pain for up to 10 days, now it is just the single prescription of Tylenol every 4 hours (Attachment #41). The MAR for the Miralax was updated by the pharmacy to match the prescription to give every 2-3 days (Attachment #42). |
07/19/2016
| Implemented |
6400.163(c) | Individual #1 had psychiatric medication reviews on 7/22/15, 11/4/15, 2/10/16, and 6/1/16. | 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. | Regulation 6400.163(c) was reviewed with the Program Manager and the House Managers on 7/12/2016 by the Assistant Director (Attachment #38). The appointments for individual #1 were made by the doctor's office in the timeframes that the doctor felt was necessary (Attachment #39) The Program Manager and House Manager will ensure that the appointments are every 3 months as long as the individual continues to take psychiatric medication. |
07/12/2016
| Implemented |
6400.164(a) | Hydrocodone 325mg was administered to Individual #1 on 5/23/16. The medication log did not include a time of administration. The administration time for Zoloft was not listed on the medication logs from January of 2015 to May of 2016. The administration time for Tylenol 325mg was not logged on the medication administration log from January of 2015 through May of 2016. | 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. | Regulation 6400.164(a) was reviewed with the Program Manager and the House Managers on 7/12/2016 by the Assistant Director (Attachment #36). The pre-printed MAR's were updated to include the administration time for Zoloft and Tylenol 325mg (Attachment #37). The Program Manager will do monitor MAR's monthly to ensure they are completed correctly. The Assistant Director will review a random sampling of MAR's throughout the year to ensure on-going compliance. |
07/12/2016
| Implemented |
6400.181(e)(7) | Individual #1's 1/15/16 assessment indicated he/she could move away from heat sources. Other sections of the assessment indicate he/she is not able to move limbs, was unable to walk, and was wheelchair bound. Individual #1 was not adequately assessed on his/her ability to sense and move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Regulation 6400.181(7) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment # 12). Individual #1 was re-assessed on 7/15/2016 by the Program Manager and the assessment indicates she is able to sense, but not move away from heat sources due to mobility issues (Attachment #13) |
07/15/2016
| Implemented |
6400.181(e)(12) | Individual #1's 1/15/16 assessment did not include 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. | Regulation 6400.181(12) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #14). Individual #1 was re-assessed on 7/15/2016 by the Program Manager, recommendations for specific areas for training, programming and services has been updated (Attachment #15) |
07/15/2016
| Implemented |
6400.181(e)(13)(i) | Individual #1's 1/15/16 assessment did not include progress over the past year in health. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Regulation 6400.181(13) (i) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #16) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in health has been updated as well (Attachment #17). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(ii) | Individual #1's 1/15/16 assessment did not include progress over the past year in motor and communication skills. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Regulation 6400.181(13) (ii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #18) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in motor and communication skills has been updated as well (Attachment #19). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(iii) | Individual #1's 1/15/16 assessment did not include progress over the past year in residential living. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Regulation 6400.181(13) (ii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #20) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in residential living has been updated as well (Attachment #21). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(iv) | Individual #1's 1/15/16 assessment did not include progress over the past year in personal adjustment. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Regulation 6400.181(13) (iv) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #22) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in personal adjustment has been updated as well (Attachment #23). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(v) | Individual #1's 1/15/16 assessment did not include progress over the past year in socialization. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Regulation 6400.181(13) (v) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #24) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in socialization has been updated as well (Attachment #25). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(vi) | Individual #1's 1/15/16 assessment did not include progress over the past year in recreation. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Regulation 6400.181(13) (vi) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #26) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in recreation has been updated as well (Attachment #27). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(vii) | Individual #1's 1/15/16 assessment did not include progress over the past year in financial independence. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Regulation 6400.181(13) (vi) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #28) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in financial independence has been updated as well (Attachment #29). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(viii) | Individual #1's 1/15/16 assessment did not include progress over the past year in managing personal property. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Regulation 6400.181(13) (viii) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #30) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in managing personal property has been updated as well (Attachment #31). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(e)(13)(ix) | Individual #1's 1/15/16 assessment did not include progress over the past year in community integration. This section was verbatim the 1/9/15 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Regulation 6400.181(13) (ix) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #32) Individual #1 was re-assessed on 7/15/2016 and the progress over the last 365 and current level in community integration has been updated as well (Attachment #33). The Program Manager will ensure that the assessment includes progress and current functioning level in all areas and Assistant Director will review a random sampling of assessments throughout the year to ensure on-going compliance. |
07/15/2016
| Implemented |
6400.181(f) | Individual #1's 1/15/16 assessment was not sent to the day program. | (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).
| Regulation 6400.181(f) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #34). The Program Manager will ensure that the assessment is sent out to all team members 30 calendar days prior to the ISP, the re-assessment for individual #1 was mailed to all team members, including day program (Attachment #35). |
07/15/2016
| Implemented |
6400.183(5) | Individual #1's Individual Support Plan (ISP) did not include the social, emotional, environmental needs plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Regulation 6400.183(5) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #10). Individual #1's SEEN plan was emailed to the SC to be included in the next ISP update (Attachment #11) |
09/01/2016
| Implemented |
6400.186(a) | The program specialist did not write the 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan (ISP) reviews. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Regulation 6400.186(a) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #1). The CHS Program Manager (Program Specialist) will be responsible for completing all portions of the ISP review. The Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. |
07/12/2016
| Implemented |
6400.186(b) | REPEATED VIOLATION - 2/17/15 Individual #1 did not date the 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan Review. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Regulation 6400.186(b) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #2). Individual #1 did attend her ISP review meetings and signed the sign off sheet but did not date. The Program Manager had the individual date the sign off sheets (Attachment #3). The CHS Program Manager will ensure that all team members date the ISP reviews and the Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. |
07/12/2016
| Implemented |
6400.186(c)(1) | The 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan reviews did not include participation and progress toward the outcomes of daily living skills and telling time. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | Regulation 6400.186(c)(1) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #4). The 7/27/16 quarterly review for individual 1 was revised to clearly show participation and progress toward the outcomes of daily living skills and telling time (Attachment #5). CHS Program Manager will ensure that all outcomes are noted on the ISP reviews. The Assistant Director will review a random sampling of ISP reviews throughout the year to ensure on-going compliance. |
07/27/2016
| Implemented |
6400.186(c)(2) | The 4/25/16, 1/15/16, and 10/26/15 Individual Support Plan reviews did not review the dental plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Regulation 6400.186(c)(2) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #6). The Program Manager will ensure that each section of the ISP specific to the residential home is included in the ISP review. The ISP review dated 7/27/2016 includes a review of Individual #1's dental plan (Attachment #5) |
07/27/2016
| Implemented |
6400.186(d) | Individual #1's ISP reviews were not sent to the day program. | 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. | Regulation 6400.186(d) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #7). The ISP review for individual #1 dated 7/27/2016 was sent to all team members, including day program (Attachment #8) |
07/27/2016
| Implemented |
6400.186(e) | An option to decline the Individual Support Plan Reviews was not sent to Individual #1's power of attorney. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Regulation 6400.186(e) was reviewed with the Program Manager and House Managers on 7/12/2016 by the Assistant Director (Attachment #9). The option to decline was added to the cover letter that is sent to all team members for each ISP review and annual assessment that is written by the Program Manager (Attachment 8a). The Assistant Director will review a random sampling of ISP reviews and correspondence throughout the year to ensure on-going compliance. |
07/27/2016
| Implemented |