| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The license for this chapter expired on 10/15/2019. A self-assessment wasn't completed until 10/16/2019. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| a. The provider¿s Operations Director will ensure that a self-assessment schedule is created, ensuring that all homes have a completed self-assessment at least 3 times per year. This schedule will be created and implemented by 11/15/19.
b. As the self-assessments were completed for all of the homes in October 2019, the schedule will begin in January 2020.
c. Self-assessments will be completed by Program Specialists, as well as the Operations Director when necessary.
d. Any non-compliant findings will be addressed and remedied upon discovery.
e. Self-assessments of all group homes will be made available to licensing representatives whenever necessary. |
11/15/2019
| Implemented |
| 6400.22(e)(1) | There were no monthly records of deposits/withdrawals for Individual #1 for the months of 5/2019, 6/2019, and 8/2019. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | a. The provider will ensure that Direct Care Workers are auditing the consumers¿ finances at the beginning of their shift, when funds are used, as well as at the end of their shift.
b. The provider will ensure that Residential Program Supervisors are checking the cash on hand forms at least once weekly, in order to catch any errors in audits or documentation.
c. The provider will ensure that Program Specialists are reviewing Cash on Hands for each consumer on a monthly basis, before turning them into the Operations Director for review.
d. The provider will ensure that both the Program Specialists as well as the Operations Director are tracking the beginning and ending balances for Cash on Hands for all consumers on a monthly basis.
e. Upon final review by the Operations Director, all Cash on Hands will be sent to the provider Rep-Payee, PB. |
11/11/2019
| Implemented |
| 6400.22(e)(3) | There were no receipts for purchases exceeding $15 for the months of 5/2019, 6/2019, 8/2019 and 9/2019. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | a. The provider will ensure that Direct Care Workers are auditing the consumers¿ finances at the beginning of their shift, when funds are used, as well as at the end of their shift.
b. The provider will ensure that when consumer¿s funds are used, a receipt for the purchase will be obtained, regardless of the amount of money spent.
c. The provider will ensure that Residential Program Supervisors are checking the cash on hand forms at least once weekly, in order to catch any errors in audits or documentation, or to find any purchases with missing receipts.
d. The provider will ensure that Program Specialists are reviewing Cash on Hands for each consumer on a monthly basis, before turning them into the Operations Director for review.
e. The provider will ensure that both the Program Specialists as well as the Operations Director are tracking the beginning and ending balances for Cash on Hands for all consumers on a monthly basis.
f. Upon final review by the Operations Director, all Cash on Hands will be sent to the provider Rep-Payee, PB. |
11/11/2019
| Implemented |
| 6400.73(a) | There are more than 2 steps leading up through the Bilco doors at this residence. There is no handrail at this exit. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | a. The provider shall ensure that each ramp, interior stairway, and outside steps exceeding two steps shall have a well-secured handrail, in compliance with 6400.73(a)
b. The Operations Director and Program Specialists shall visually inspect all ramps, interior stairways, and outside steps, including Bilco doors, on a routine and ongoing basis. Instances of noncompliance will be reported and corrected by creating a work order for the maintenance department through the maintenance reporting system, Manager Plus.
c. The provider¿s Operations Director, Laura Mashack, created a work order to install the missing railing at the Bilco doors at Lawndale Road on 10/22/19. The provider¿s head of the maintenance department installed the railing on 10/24/19. |
10/24/2019
| Implemented |
| 6400.112(e) | The last sleep drill at this residence was held on 9/1/2018, which exceeds the 6 month requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | a. The provider¿s Operations Directors will ensure that unannounced monthly fire drills are being completed by following the schedule of drills that has been made.
b. The Program Specialist for the home will be responsible for assigning the drill to the appropriate staff.
c. The Program Specialist and Operations Director of each home will be tracking the monthly fire drills on a spreadsheet, ensuring that the dates, times, hypothetical locations, exits used, and staff conducting the drill are varied.
d. Upon receiving of the completed and accurately documented drill, Program Specialists will be responsible for making 2 copies, one for their records, and one for the Operations Director.
e. The Operations Director will keep a master fire book of all monthly drills for each group home.
f. Program Specialists and the Operations Director will ensure that asleep fire drills are held at least every six months, every April and October. |
11/11/2019
| Implemented |
| 6400.141(c)(14) | This section was blank on Individual #1's physical exam dated 4/22/2019. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | a. The provider will ensure that all necessary information on each physical exam is complete, in accordance with regulation 6400.141.
b. The provider will ensure that all information is included and accurate by re-training the appropriate parties, residential program supervisors, residential program specialists, as well as the operations director, on 11/12/19.
c. The provider will ensure that upon completion of a physical, the residential program supervisor will check over the entire document for completion and accuracy of necessary information.
d. The provider will ensure that the residential program supervisor will turn the physical exam into their residential program specialist upon completion and verification of accuracy of necessary information. The provider¿s program specialist will then check for completion and accuracy of the necessary information on the annual physical.
e. The provider will ensure that upon verification of accuracy by the residential program specialist, the annual physical will then be turned into the operations director for a final review of thoroughness and accuracy.
f. Any physicals that are found to have inaccurate or missing information will be returned to the residential program supervisor with instructions of returning to the Dr. in question. Physicals will not be accepted as complete until all necessary information is present and accurate.
g. The provider¿s residential program supervisor will ensure that the missing information regarding Individual #1¿s medical information pertinent to diagnosis and treatment in case of emergency is filled in accurately and reviewed by the Dr. completing the physical exam by 11/15/19. |
11/15/2019
| Implemented |
| 6400.141(c)(15) | This section was blank on Individual #1's physical exam dated 4/22/2019. | The physical examination shall include:Special instructions for the individual's diet. | a. The provider will ensure that all necessary information on each physical exam is complete, in accordance with regulation 6400.141.
b. The provider will ensure that all information is included and accurate by re-training the appropriate parties, residential program supervisors, residential program specialists, as well as the operations director, on 11/12/19.
c. The provider will ensure that upon completion of a physical, the residential program supervisor will check over the entire document for completion and accuracy of necessary information.
d. The provider will ensure that the residential program supervisor will turn the physical exam into their residential program specialist upon completion and verification of accuracy of necessary information. The provider¿s program specialist will then check for completion and accuracy of the necessary information on the annual physical.
e. The provider will ensure that upon verification of accuracy by the residential program specialist, the annual physical will then be turned into the operations director for a final review of thoroughness and accuracy.
f. Any physicals that are found to have inaccurate or missing information will be returned to the residential program supervisor with instructions of returning to the Dr. in question. Physicals will not be accepted as complete until all necessary information is present and accurate.
g. The provider¿s residential program supervisor will ensure that the missing information regarding Individual #1¿s diet is filled in accurately and reviewed by the Dr. completing the physical exam by 11/15/19. |
11/15/2019
| Implemented |
| 6400.144 | According to Individual #1's MAR sheets, his blood pressure is to be taken daily at 1PM. There is no documentation that his blood pressure was taken on 7/19/2019 and 10/9/2019. | 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.
| a. The provider will ensure that all health services, including medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
b. The provider will ensure that all staff working with Individual #1 are trained on all of his medical needs, including ensuring that his blood pressure is taken at 1PM daily.
c. The provider will ensure that all staff working with Individual #1 who have already been trained on Individual #1¿s medical needs, including his blood pressure being taken daily at 1PM, are re-trained before 11/15/19.
d. The provider will ensure that neglect incidents will be entered for failure to comply with medical services that have been planned or prescribed for all individuals. Neglect incidents will be accompanied by an investigation with the suspension of the target staff. |
11/15/2019
| Implemented |
| 6400.181(a) | Individual #1's most current assessment is dated 5/4/2018, which exceeds the annual requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | a. The Provider will ensure that all assessments are completed and sent to the team at least 30 days prior to the ISP meeting, in compliance with Chapter 6400.181(a).
b. The provider¿s program specialist, MS, completed an updated annual assessment for NS on 11/7/19.
c. The provider¿s operations director, AM, and regional director, CM, compiled a list of due dates for all consumers¿ assessments, quarterly meetings, and IPS¿s. This list has been shared with the Program Specialists, in order to ensure that all assessments are completed and sent to appropriate team members on time.
d. The provider¿s operations director, AM, is adding the assessment due date to the monthly spot-check form that supervisors will be filling out and turning in for review on a monthly basis. |
11/11/2019
| Implemented |
| 6400.165(g) | Individual #1's last psych med review was completed on 3/27/2019, which exceeds the 3 month requirement. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | a. The provider will ensure that all medication prescribed to treat a diagnosed psychiatric illness are reviewed by a licensed physician every three months according to regulation.
b. The residential program supervisors will ensure that the provider¿s medical compliance specialist, CS, is made aware of all psychiatric medication review appointments.
c. The provider will ensure that the previous and the upcoming psychiatric medication review appointments are listed on a monthly spot check form, which will be completed by the residential program supervisors for each consumer on a monthly basis. |
11/11/2019
| Implemented |
| 6400.166(b) | Individual #1 was prescribed Amoxicillin (500-125mg) BID for 10 days. This medication was not initialed as administered at 8PM on 10/11/2019. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | a. The provider will ensure that prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.
b. Immediate corrective action implemented by explaining the documentation error on the back of the medication log. Staff administered the 8PM dose of Amoxicillin on 10/11/19 but failed to sign on the MAR. The missed dose was circled in red and explained as a documentation error by residential program supervisor RB.
c. Residential program supervisors will be re-trained on the responsibilities of checking through the medication administration record on a daily basis. Training to take place on 11/12/19. Any discrepancies in documentation or administration of medication will be documented as reported as necessary, with a medication error being entered into EIM whenever applicable.
d. Staff who fail to document or administer medications as trained and per regulations will be required to be re-trained through the department-approved medication administration class. These staff will also be required to complete 4 additional medication practicums with a trained medication administration observer. |
11/12/2019
| Implemented |