| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual #1's nebulizer mask was covered with food particles and dead skin. | Clean and sanitary conditions shall be maintained in the home. | Individual #1's nebulizer mask was cleaned on 5/9/16, attachment (3rd Ave #4). On 5/11/16 Individual #1's nebulizer mask was added to the Daily Activity List, attachment (3rd Ave #5). On 6/1/16, Assistant Vice President trained Directors/Managers on their responsibilities to maintain clean and sanitary conditions, see attachment (St. Paul #2). Managers will train staff on their responsibilities to maintain clean and sanitary conditions by 6/30/2016, attachment (3rd Ave #3). |
06/30/2016
| Implemented |
| 6400.67(a) | Individual #1's shower chair is stained brown. The material on the back of the chair is not supportive and over stretched. | Floors, walls, ceilings and other surfaces shall be in good repair. | Administrative Coordinator ordered two new shower chair backs for Individual #1's shower chair on 6/3/16, attachment (3rd Ave #6). On 6/1/16, Assistant Vice President trained Directors/Managers on their responsibilities that floors, walls and ceiling shall be in good repair, see attachment (St. Paul #2). Managers will train staff on their responsibilities that floors, walls and ceiling shall be in good repair, (3rd Avenue #3) by 6/30/16 |
06/30/2016
| Implemented |
| 6400.103 | The written evacuation plan does not include individual responsibilities in the event of an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Administrative Coordinator revised the written evacuation plan to include individual responsibilities in the event of an emergency on 6/3/16, see attachment, (3rd Ave. #1). The Administrative Coordinator revised Emergency Evacuation Plans for 15 homes on 6/3/16, see attachment (6th Street #2). The Director/Manager will review with individuals their responsibilities on the revised evacuation plan by 7/30/16, (attachment 3rd Ave #8). |
07/30/2016
| Implemented |
| 6400.104 | The 5/1/16 notification letter does not indicate the bedrooms of the individuals who need assistance to evacuate. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Administrative Coordinator indicated the bedrooms of the individuals who need assistance to evacuate and notified the local fire department in writing on 5/31/16, attachment (3rd Ave #7). On 5/31/16 the Administrative Coordinator notified the fire department in writing of the location of the individuals who need assistance to evacuate for 15 homes, attachment (6th St. #2). |
05/31/2016
| Implemented |
| 6400.112(a) | The staff communication log contained a note, dated 4/1/16, that requested the staff mmeber on shift conduct a fire dril on 4/3/16. All staff have access to the communication log. | An unannounced fire drill shall be held at least once a month. | Assistant Vice President trained current managers/directors on their responsibilities of unannounced fire drills on 6/1/2016, see attachment (St. Paul #2). An unannounced fire drill was held on 6/3/2016, see attachment (3rd Ave #2). Managers will train staff on their responsibilities of unannounced fire drills by 6/30/2016, attachment (3rd Ave #3). |
06/30/2016
| Implemented |
| 6400.143(a) | Individual #1 refused to complete his/her wrist splint treatment recommended by his/her physician. A refusal of treatment plan was not in place. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1's physical therapist discontinued his wrist splint on 6/2/16, attachment (3rd Ave #14). Assistant Vice President will train Program Directors on Regulation 6400.143(a) and documentation and follow up, attachment (3rd Ave # 17). |
06/30/2016
| Implemented |
| 6400.144 | Individual #1's record included a health promotion plan recommended by his/her physician that indicated he/she is to be out of his/her wheelchair every 2 hours for 30 minutes to prevent pressure sores. The plan indicated staff will document daily the times that he/she is out of the wheelchair. Staff are not documenting the time Individual #1 is placed in or taken out of the wheelchair. Individual #1's physical therapist recommended hand splits to be worn for 2 hours and taken off for 2 hours or as Individual #1 tolerates. Individual #1 refused to wear the hand splints In March and April of 2016. No follow up was sought. There were 4 days in February of 2016 that staff documented the amount of time the hand splints were worn. On 4/3/16, Staff #1 entered a note into the communication log that indicated "it looked like Individual #1 was having a seizure. He/she stiffened, mouth was clenched slobbery white foam and sweating bad. Lasted 2 or 3 minutes then he was fine." There was no medical attention sought for Individual #1. | 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.
| Individual #1 health promotion plan was revised on 6/3/16 to include the Physical Therapist's recommendation that occurred on 6/2/16, attachment (3rd Ave #13 & #14). Hand splints were discontinued (3rd Ave #14). Program Director will review with 3rd Avenue staff documentation and follow up on any concerns by 6/30/16, (3rd Ave #15). A HCQU training on Seizures was scheduled 5/26/16 and cancelled by HCQU Nurse and rescheduled for 6/7/16, (3rd Ave #16). |
06/30/2016
| Implemented |
| 6400.167(b) | Individual #1 is prescribed Polyethylene Glycol 3350 powder to be administered twice daily as needed for severe constipation. Polyethylene Glycol 3350 powder was administered twice daily in March and April of 2016. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1's prescription Polyethylene Glycol 3350 powder prescription was changed to twice daily on 5/5/16. On 6/1/16 Assistant Vice President trained Directors/Managers on Regulation 6400.167(b) and the purpose of PRN medications, attachment (3rd Ave. #10). Managers will train staff on Regulation 6400.167(b) and the purpose of PRN medications, attachment (3rd Ave. #11) by 6/30/16. The Director will review PRN medications to ensure physician's recommendations are followed by 6/30/16, attachment (3rd Ave #12). |
06/30/2016
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in health. This section was verbatim the 1/22/15 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.
| On 6/3/16, the Director revised Individual #1's assessment to include a change in his health status which was identified at an appointment on 11/4/15, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in residential living. This section was verbatim the 1/22/15 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. | On 6/3/16, the Director revised Individual #1's assessment to include a change in activities of residential living, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in personal adjustment. | 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. | On 6/3/16, the Director revised Individual #1's assessment to include a change in personal adjustment, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in socialization. | 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. | On 6/3/16, the Director revised Individual #1's assessment to include a change in socialization, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in recreation. | 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. | On 6/3/16, the Director revised Individual #1's assessment to include a change in recreation, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in financial independence. | 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.
| On 6/3/16, the Director revised Individual #1's assessment to include a change in financial independence, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's 1/12/16 assessment did not include progress or regression over the past year in managing personal property. | 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. | On 6/3/16, the Director revised Individual #1's assessment to include a change in managing personal property, attachment (3rd Ave #20). On 6/2/16, Assistant Vice President trained Directors on Assessment Regulations content 181(a)-181(f), attachment (3rd Ave #9). |
06/03/2016
| Implemented |
| 6400.186(c)(1) | Individual #1's 4/4/16, 10/4/15, 7/4/15, and 4/5/15 Individual Support Plan (ISP) reviews did not include Individual #1's participation and progress on the ISP outcomes of Growth and Development and Home. | 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. | On 6/2/16 Assistant Vice President trained Program Directors on Regulations 6400.186(c)(1) attachment (3rd Ave, #9). Growth and development is an outcome Individual #1's participates in at his day program. Program Director will include participation and progress on Individual #1's ISP Review due 7/4/16, attachment (3rd Avenue #18). |
07/15/2016
| Implemented |
| 6400.186(c)(2) | Individual #1's 4/4/16, 10/4/15, 7/4/15, and 4/5/15 Individual Support Plan (ISP) reviews did not include an update on Individual #1's social, emotional, environmental needs plan and did not review his/her community activities. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | On 6/2/16 Assistant Vice President trained Program Directors on Regulations 6400.186(c)(2) attachment (3rd Ave, #9). Program Director will include an update on social, emotional, environmental needs plan and community activities on Individual #1's ISP Review due 7/4/16, attachment (3rd Avenue #18). |
07/15/2016
| Implemented |
| 6400.213(11) | Individual #'1s Individual Support Plan indicated Individual #1 is to be out of his/her wheelchair every 2 hours for 30 minutes. The 1/12/16 assessment indicated Individual #1 is to be out of his/her wheelchair every 2 hours for 20 minutes. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | On 6/2/16 Physical Therapist wrote new orders for Individual #1 wheelchair re-positioning, attachment (3rd Ave #14). Program Director notified Supports Coordinator of the new orders on 6/6/16, attachment (3rd Ave #19). Program Director revised assessment on 6/3/16 to include new orders, attachment (3rd Ave #20). |
06/06/2016
| Implemented |