| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.185(b) | Individual #1's ISP updated 7/28/17 stated that sharps in the home are to be locked. The cabinet in the kitchen containing the kitchen knives and sharp objects were left unlocked and accessible to Individual #1. | The ISP shall be implemented as written. | During licensing inspection on 8/31/2017, Residential Director locked the cabinet in the kitchen containing the kitchen knives and sharp objects.
Residential Directors reviewed individual¿s records who require the sharps to be locked and verified they are locked within their home by 9/21/2017 (see Elmira Attachment #7).
On 9/6/2017, Residential Coordinator trained Residential Directors and Habilitation Managers on Regulation 6400.185(b) to ensure ISP¿s are implemented as written to include locking sharps (see Elmira Attachment #1).
Residential Directors/Habilitations Managers will train current habilitation staff on Regulation 6400.185(b) to ensure ISP¿s are implemented as written to include locking sharps by 10/6/2017 (Elmira Attachment #2). |
10/06/2017
| Not Implemented |
| 6400.213(1)(i) | Individual #1'record did not contain identifying marks. There was a section for identifying marks on his/her personal data sheet however it stated under this section "native American" | 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. | On 9/8/2017, Residential Director revised Individual #1¿s Personal Data Sheet to include the section for identifying marks (see Elmira Attachment #4).
Residential Director reviewed individual¿s records to verify personal data sheets include identifying marks by 9/21/2017 (see Elmira Attachment #3).
On 9/6/2017, Residential Coordinator trained Program Specialists on Regulation 6400.213(1)(i) to ensure all Individual personal information includes identifying marks (see Elmira Attachment #1). |
09/21/2017
| Implemented |
| 6400.213(11) | Repeat 7/13/17: Individual #1's ISP updated 7/28/17 states he/she has a diagnosis of Bi-Polar. Individual #1's assessment completed on 3/3/17 under Individual #1's disabilities did not state Bi-Polar as a diagnosis but did list Depression as a diagnosis. Individual #1's physical dated 3/20/17 lists depression as a diagnosis and does not indicate a diagnosis of Bi-Polar. Individual #1's Individual Support Plan (ISP) indicates that sharps are locked in the home however this is not indicated in his/her assessment. Individual #1's ISP states under community supervision "should be within arm's length supervision with anyone under the age of 18". Individual #1's assessment did not indicate any arm's length supervision was needed. It only discussed the protocol for accessing the bathroom while out in the community with Individual #1. Individual #1's ISP states under the adaptive self-help area that Individual #1 needs reminded to take small bites, chew slowly and not put more in his/her mouth until he/she is finished with the first bite. Individual #1's assessment completed 3/3/17 did not indicate that Individual #1 needs any assistance with eating. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | On 9/12/2017, Residential Director consulted with Individual #1¿s physician to clarify his current Diagnosis and updated his records (see Elmira Attachment #5 and #6).
On 9/20/2017, Residential Director revised Individual #1¿s Assessment to indicate that sharps needs to be locked (see Elmira Attachment #6).
On 9/20/2017, Residential Director revised Individual #1¿s Assessment to indicate his current supervision needs (see Elmira Attachment #6).
On 9/20/2017, Residential Director revised Individual #1¿s Assessment to indicate his skills while eating (see Elmira Attachment #6).
On 9/6/2017, Residential Coordinator trained Residential Directors and Habilitation Managers on Regulation 6400.213(11) to ensure all individual records include content discrepancy in the ISP (see Elmira Attachment #1). |
09/21/2017
| Not Implemented |
| 6400.216(a) | An unlocked filing cabinet in the basement of the home contained purged Individual Support Plans and documents of individuals who no longer lived at the home. | An individual's records shall be kept locked when unattended. | During the onsite inspection on 8/31/2017, Habilitation Staff removed the purged Individual Support Plans and documents of Individuals who no longer lived in the home from the home to the main facility and were shredded.
On 9/6/2017, Residential Coordinator trained Residential Directors and Habilitation Managers on Regulation 6400.216(a) to ensure all individual records shall be kept locked when unattended (see Elmira Attachment #1).
Residential Directors/Habilitations Managers will train current habilitation staff on Regulation 6400.216(a) to ensure all individual records shall be kept locked when unattended by 10/6/2017 (Elmira Attachment #2).
Residential Directors reviewed individual¿s homes to verify all individual records are kept locked when unattended by 9/21/2017 (see Elmira Attachment #3). |
10/06/2017
| Implemented |