| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual #1's bathroom shower was very dirty- pink mold, and the floor was dirty and paper on the floor. | Clean and sanitary conditions shall be maintained in the home. | The identified areas have been resolved by responsible consumer and staff. Best practice was reviewed with responsible administrative staff of the home and processed with support staff. At the time of licensing, IFC¿s home inspections were routinely done by the home¿s assigned program managers. Per the recommendation of licensing representative, these inspections will be done by program managers of other homes to limit their familiarity and potential missed observations. Attachments 1 and 2 represents the completed work order and picture. |
03/28/2018
| Implemented |
| 6400.67(a) | The sink in individual #1's was very rusted cabinet arm of sink and the front and bottom of the cabinet. | Floors, walls, ceilings and other surfaces shall be in good repair. | The sink had surface prepared and new paint applied to all impacted metal components. At the time of licensing, IFC¿s home inspections were routinely done by the home¿s assigned program managers. Per the recommendation of licensing representative, these inspections will be done by program managers of other homes to limit their familiarity and potential missed observations. Attachments 1 and 2 represents the completed work order and picture. |
03/28/2018
| Implemented |
| 6400.162(a) | Individual #1's medication label for Ary Saline nasal gel did not contain a label with all information including the person, amount, time, and way to administer. | 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. | Attachment 6 is the nasal spray label that was corrected following licensing survey. In coordination with PCP, this medication was subsequently discontinued. Attachment 7 is the order for discontinuation. This home¿s staff received additional training on 3/7/18 regarding a variety of documentation and medication administration issues pertinent to the issues noted during the survey as well as IFC¿s own review. Attachment 8 is training sheet from the identified meetings. |
03/28/2018
| Implemented |
| 6400.164(a) | Individual #1's Ary Saline nasal spray was discontinued by the doctor on 12/1/17. On the medication log for December the Ary Saline nasal gel was discontinued instead. | 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. | This consumer had two nasal medications ordered. Upon discontinuation of one medication, staff discontinued the opposite medication on the med log but continued to administer correctly. This documentation error was unnoticed during our nursing reviews as well. The only distinction between medications was a code on the med log distinguishing saline from gel form. This distinction was reviewed with nursing staff and responsible residential staff at staff meetings on 3/7. The documentation webcast from the department¿s med admin training was also viewed at this time. Contact was also made with the pharmacy to review protocol for medication discontinuance. IFC has also hired a second nurse who will be sharing review duties. Attachment 8 is training sheet from the identified meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level in activities of residential living. | 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(iv) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level 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.
| IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 12/27/17 did not include progress over the last 365 calendar days and current level in community integration. | 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. | IFC¿s assessment format has been revised to require a better flow of information. The updated format forces those completing them to identify background information for each of the relevant sections separately from growth and progress. Training with Program Specialists occurred on 3/5/18 at our routine administrative meeting. The updated format was reviewed as well as guidance on staff interviews for the preparation of assessments. Additionally, an annotated guide to assessments was created to support staff in generating consistent, thorough reports. Assessments were completed by each of the program specialists utilizing the new guidance to insure compliance. Attachment 17a includes an addendum to both cited assessments. Attachment 17b includes an assessment from each of the cited Program Specialists completed using the new format.. Attachment 18 includes training sheet for 3/5/18 meeting. |
03/28/2018
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews did not review community integration on 7/27/17 and 10/26/17. The information was exactly the same for both. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | During a review and training regarding assessments on 3/7/18, the hazards of cutting and pasting between documents was highlighted. It was reinforced that this applies to all programming documents. Staff were directed to start anew with each. Attachment 18 is record of meeting date. Program Specialists will be required to demonstrate compliance through quarterly supervisory review of waiver books. Attachment 14 demonstrates a current quarterly demonstrating adequate documentation for outcome areas. An addendum to the POC will be sent for the cited individual when next quarterly is due demonstrating correction. |
04/30/2018
| Implemented |