| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 has a seizure protocol in place stating that 911 is to be contacted if a seizure lasts longer than 5 minutes. It was documented that Individual #1 had a seizure on 2/19/17 at 2:05 am lasting 15 minutes and there is no documentation that 911 was called. Individual #1 had a seizure on 5/14/17 at 10:20 pm lasting 10 minutes and there is no documentation that 911 was called. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Residential Coordinator filed a Neglect Incident report for not contacting 911 on 2/19/2017 and 5/14/2017 (see Miller Attachment #7).
Vice President of Residential Services trained Assistant Vice President, Administrative Coordinator, Residential Coordinator, Residential Directors and Habilitation Managers on Regulation 6400.18(c) (See Elwood Attachment #3).
Residential Directors and Habilitation Managers will train current Habilitation staff on Regulation 6400.18(c) by 8/18/2017 (Elwood Attachment #4).
Staff #1 and Habilitation Manager of the home are no longer employed by the agency. |
08/18/2017
| Not Implemented |
| 6400.18(c) | On Individual #1's Individual Support Plan (ISP) review dated 7/9/17, Staff #1 documented on page 5 that Individual #1 had a seizure on 5/14/17 at 10:20 pm and that he/she was sleeping in the bed. The length of the seizure was not noted in the ISP review. The seizure log kept on record does state the seizure lasted 10 minutes and there is no documentation 911 was notified. | The home shall orally notify the county Intellectual Disability program of the county in which the home is located, the funding agency and the appropriate regional office of Intellectual Disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| Residential Coordinator filed a Neglect Incident report for not contacting 911 on 2/19/2017 and 5/14/2017. Upon the Residential Coordinator becoming aware of this incident, notification to the county, the funding agency and the appropriate regional office on intellectual disability was completed within 24 hours. (see Individual #1 Attachment #7).
Vice President of Residential Services trained Assistant Vice President, Administrative Coordinator, Residential Coordinator, Residential Directors and Habilitation Managers on Regulation 6400.18(c) to include notification of incidents within 24 hours (See Individual #1 Attachment #3).
Staff #1 and Habilitation Manager of the home are no longer employed by the agency. |
07/27/2017
| Not Implemented |
| 6400.72(b) | The screen door leading from the kitchen to the patio is broken and off the track. | Screens, windows and doors shall be in good repair. | Administrative Coordinator ensured the screen door was repaired (see Miller Attachment #16).
Residential Director checked all screen doors are in good repair in each home. Administrative Coordinator will ensure all screen doors are in good repair in each home (see Elwood Attachment #2).
Vice President of Residential Services trained Assistant Vice President, Administrative Coordinator, Residential Coordinator, Residential Directors and Habilitation Managers on Regulation 6400.72(b) (See Elwood Attachment #3).
Residential Directors and Habilitation Managers will train current Habilitation staff on Regulation 6400.72(b) to include all screen doors in good repair by 8/18/2017 (Elwood Attachment #4). |
08/18/2017
| Implemented |
| 6400.74 | The steps to the attic did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Administrative Coordinator ensured the attic steps have a nonskid surface (see Miller Attachment #15).
Residential Directors checked all steps to have a nonskid surface in each home. The Administrative Coordinator will ensure all steps have nonskid surfaces in each home (see Elwood Attachment #2).
Vice President of Residential Services trained Assistant Vice President, Administrative Coordinator, Residential Coordinator, Residential Directors and Habilitation Managers on Regulation 6400.74 (See Elwood Attachment #3).
Residential Directors and Habilitation Managers will train current Habilitation staff on Regulation 6400.74 by 8/18/2017 (Elwood Attachment #4) |
08/18/2017
| Implemented |
| 6400.144 | Repeat 2/23/17: Individual #1's seizure protocol states that 911 is to be contacted for a seizure lasting over 5 minutes. On 2/19/17 and 5/14/17 Individual #1 had a seizure lasting over 5 minutes and 911 was not contacted. The seizure protocol was not followed. Individual #1 had a scheduled neurology appointment with Dr. Olinsky on 1/4/17 that he/she did not attend. There is no documentation in the record as to why this appointment was missed. It is documented on 1/23/17 that the doctor office was contacted to reschedule the appointment and it was rescheduled for 3/20/17 at 11:30 am. Individual #1 has a weight management protocol stating that he/she must see his/her primary care physician if he/she drops five pounds or more. This is stated in Individual #1's ISP updated 6/30/17. On 1/22/17 Individual #1 weighed in at 103.5 pounds and on 2/26/17 he/she weighed in at 97.5 pounds. This is a 6 pound weight loss and there is no documentation that Individual #1 was seen by his/her primary care physician. Individual #1 was prescribed Milk of Magnesia Suspension 30 ML by mouth if no bowel movement for three days followed by a full glass of water/liquid. It is documented that Individual #1 did not have a bowel movement on 4/21/17, 4/22/17 and 4/23/17 and there is not documentation that he/she was administered the Milk of Magnesia medication. | 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.
| Residential Coordinator filed a Neglect Incident report for not contacting 911 on 2/19/2017 and 5/14/2017 (see Individual #1 Attachment #7).
Residential Director had Individual #1's seizure protocol reviewed and confirmed by her neurologist. Residential Coordinator re-trained current staff on the reviewed seizure protocol (see Individual #1 Attachment #8).
Residential Directors reviewed all current individuals¿ record to verify seizure protocol and documentation is being followed (see Individual #1 Attachment #9).
As part of the Directed Corrective Action Plan effective March 1, 2017: The Residential Directors will review scheduled appointments on a weekly basis to ensure staff are available and knowledgeable about the location of the appointment. Missed appointments, the reason for the absence, attempts to reschedule an appointment and supervisory notification within the agency will be documented in a centralized location for regular audit by the CEO.
Program Support Specialist had Individual #1's weight protocol clarified by her Primary Care Physician. Residential Coordinator developed and implemented a Weight Protocol for Individual #1. This included updating Individual #1¿s team and training current staff (see Individual #1 Attachment #10).
Residential Directors reviewed all current individuals¿ record to verify weight protocols and documentation is being followed (see Individual #1 Attachment #11).
Program Support Specialist filed a Medication Error for not administering Milk of Magnesia Suspension on 4/23/2017 for no Bowel Movement in 3 days. Residential Coordinator completed a Medication error debriefing (see Individual #1 Attachment #12).
Residential Coordinator developed and implemented a Bowel Management Protocol for Individual #1. This included updating the Individual #1's team and training current staff (see Individual #1 Attachment #13).
Residential Directors reviewed all current individuals' record to verify Bowel Movement protocols and documentation is being followed (see Individual #1 |
08/18/2017
| Not Implemented |
| 6400.167(b) | Individual #1 is prescribed Phenytoin 50 mg for his/her seizures. The medication bottle and medication admininstration record for Individual #1's Phenytoin 50 mg states "chew two tablets by mouth in the morning daily and two tablets by mouth at bedtime daily" however Individual #1 is unable to chew. Staff reported to licensing representative that they have been administering his/her medication by crushing it and putting it in applesauce. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Program Support Specialist had Individual #1¿s Phenytoin 50mg medication clarified with the ordering physician. Residential Coordinator updated Individual #1¿s team on how her medications are administered (see Individual #1 Attachment #5).
Residential Directors will review all current individuals¿ record to verify medications are administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician¿s assistant by 8/18/2017 (Individual #1 Attachment #6).
Vice President of Residential Services trained Residential Directors and Habilitation Managers on Regulation 6400.167(b) to ensure medications are administered to the directions specified by licensed physician, certified nurse practitioner or licensed physician¿s assistant (see Individual #1 Attachment #3).
Residential Directors and Habilitation Managers will train Habilitation staff on Regulation 6400.167(b) to ensure medications are administered to the directions specified by licensed physician, certified nurse practitioner or licensed physician¿s assistant by 8/18/2017 (Individual #1 Attachment #4). |
08/18/2017
| Implemented |
| 6400.181(e)(3)(iii) | Repeat 2/23/17: Individual #1's assessment dated 11/2/16 did not include progress and growth in the area of personal adjustment. Individual #1 has a social, emotional, environmental support plan in place and this was not documented in his/her assessment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Residential Coordinator updated Individual #1¿s Assessment to include the level of performance and progress in personal adjustment to include SEEN plan (see Individual #1 Attachment #3).
Residential Coordinator trained Residential Directors on Regulation 6400.181(e)(3)(iii) to ensure all SEEN plans are in the Assessment (see Individual #1 Attachment #2 and see Individual #1 Attachment 4). |
07/27/2017
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment completed 11/2/2016 did not include progress and growth in the area of health. The assessment did not include Individual #1's protocols of range of motion, seizure, bowel movement, dysphagia diet, ambulation, weight chart and dental hygiene plan. | 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.
| Residential Coordinator updated Individual #1¿s Assessment to include the level of performance and progress in health to include individual protocols (see Miller Attachment #3).
Residential Coordinator trained Residential Directors on Regulation 6400.181(e)(3)(iii) to include all individual protocols (see Miller Attachment #2 and see Miller Attachment #4). |
07/27/2017
| Implemented |
| 6400.213(11) | Individual #1 is allergic to penicillin with potassium. His/Her current Individual Support Plan updated 6/30/17 states he/she is allergic to penicillin. Individual #1's physical dated 4/17/17 states he/she is allergic to penicillin. Hope staff indicated that Individual #1 is only allergic to penicillin with potassium, not all penicillin. The ISP and physical do not specify that he/she is only allergic to penicillin with potassium and not all penicillin. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Residential Director had Individual #1¿s allergies clarified with her Primary care Physician. Residential Director updated Individual #1¿s team regarding the allergy clarification. (see Individual #1).
Residential Coordinator trained Residential Directors on Regulation 6400.213(11) and the importance of documenting all discrepancies. (see Individual #1 Attachment #2). |
07/27/2017
| Not Implemented |