| 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 10/18/2019. | 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 |
| 6400.151(a) | Staff #1 had a physical exam on 7/25/2017. He didn't have another physical exam until 9/16/2019, which exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | a. The provider will ensure that all staff who come into direct contact with consumers, or those who prepare and / or serve food for more than 5 days in a 6-month period, will have a bi-annual physical and mantoux test completed in compliance with 6400.151(a).
b. No immediate corrective action was available.
c. All necessary staff physical dates will be added into Relias Learning Management System, RLMS, the Provider¿s online training and learning management system.
d. Reports will be run through RLMS on a weekly basis, with any and all expiring upcoming physicals being listed on the report.
e. The Provider¿s program coordinator, program specialists, onboarding specialist, training coordinator, Operations Director, as well as Regional Director will be given access to the report.
f. The provider¿s program coordinator will ensure that all necessary expiring upcoming physicals are being completed before the date of non-compliance.
g. Those staff who fail to stay in compliance with the date of previous physical exam will be removed from the workforce and placed on administrative leave until they have completed their physical and mantoux test. |
11/11/2019
| Implemented |
| 6400.151(c)(2) | Staff #1 had a TB test on 7/26/2017. He didn't have another TB test until 9/20/2019, which exceeds the requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | a. The provider will ensure that all staff who come into direct contact with consumers, or those who prepare and / or serve food for more than 5 days in a 6-month period, will have a bi-annual physical and mantoux test completed in compliance with 6400.151(c)(2).
b. No immediate corrective action was available.
c. All necessary staff physical dates will be added into Relias Learning Management System, RLMS, the Provider¿s online training and learning management system.
d. Reports will be run through RLMS on a weekly basis, with any and all expiring upcoming physicals being listed on the report.
e. The Provider¿s program coordinator, program specialists, onboarding specialist, training coordinator, Operations Director, as well as Regional Director will be given access to the report.
f. The provider¿s program coordinator will ensure that all necessary expiring upcoming physicals are being completed before the date of non-compliance.
g. Those staff who fail to stay in compliance with the date of previous physical exam will be removed from the workforce and placed on administrative leave until they have completed their physical and mantoux test. |
11/11/2019
| Implemented |
| 6400.52(a)(1) | Staff #1 did not complete 24 hours training in most recent complete training year (calendar 2018) -- completed 19.75 hours. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | a. The provider will ensure that program specialists and direct service workers who are employed more than 40 hours per month have at least 24 hours of training relevant to human services training within the previous annual training year.
b. As the calendar year has passed, it is not possible to remedy the immediate citation.
c. To prevent reoccurrence of the deficient practice, all staff training hours will be tracked in a centrally maintained database. The maintenance of this database will be assigned to an appropriate administrative resource.
d. The database will be updated on a daily basis to account for all training hours completed. This update will be completed by the assigned administrative resource.
e. On a quarterly basis, each employee¿s annual training hours will be provided to the Regional Director. The Regional Director and assigned regional training staff will be responsible to review and ensure that each employee has an adequate number of training hours for the annual training year.
f. If at the end of the annual training year, an employee does not have an adequate number of training hours, they will be removed from the workforce and placed on administrative leave status until they have the requisite 24 hours of training time. Employees who fail to obtain the required training hours may be subject to the provider¿s progressive discipline process. |
11/11/2019
| Implemented |
| 6400.169(a) | Staff #1 had his Med Practicum on 5/24/2018. He didn't complete another practicum until 7/2/2019, which exceeds the annual requirement. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | a. The provider will ensure that all staff who have successfully completed the approved department medication administration course and are responsible for giving medications to consumers will have bi-annual and annual medication practicums completed.
b. The medication administration practicums will be completed by residential program supervisors, Program Specialists, Directors, as well as the Training Coordinator and Onboarding Specialist whenever necessary.
c. The above listed staff will complete the medication administration practicums after successfully completing the Department-approved Medication Administration Observer class.
d. The provider¿s Onboarding Specialist and Training Coordinator will be responsible for verifying that all necessary medication practicums are completed, with appropriate documentation being accurately completed.
e. Any employee who fails to complete the necessary medication administration practicums will be removed from the workforce and placed on administrative leave until they have the necessary practicum and documentation complete.
f. Staff #1 completed the Department-approved medication administration course on 10/30/19 and 10/31/19.
g. Staff #1 was observed completing 4 medication administration practicums on 10/31/19 by Training Coordinator LP, as well as Residential Program Supervisor AR. |
10/31/2019
| Implemented |