| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment that was completed dated 8/25/23 through 9/17/23 indicated a violation for regulation 141b and 165b but did not have an attached summary of correction.
The self-assessment that that was completed for dated 8/25/23 through 9/15/23 indicated a violation for 151a, and 165g but did not have an attached summary of correction.
The self-assessment that was completed for dated 8/25/23 through 9/15/23 indicated a violation for regulation 166b but did not have an attached summary of correction.
The self-assessment that was completed for dated 8/25/23 through 9/16/23 indicated a violation for regulation 151a but did not have an attached summary of correction.
The self-assessment that was completed for dated 8/25/23 through 9/15/23 indicated a violation for regulation 141c6, 144, 165b but did not have an attached summary of correction.
This home also had attached summary of corrections for regulations 142(b-h) but these were not marked as violations on the scoresheet.
The self-assessment that was completed for dated 8/25/23 through 9/15/2023 indicated violations for regulations 141c4, 151a, and 166b but did not have an attached summary of corrections.
15c -- Self-assessment begin date of 12/1/2022 and end date of 2/28/2023 lists citations for 141c and 142a -- 142h. There is no written summary of corrections made available for the 9 citations.
15c -- Self-assessment begin date of 12/14/2022 and end date of 2/18/2023 lists citation for 32r, 112a, 112b, 141a, 141c, 181c and 181f. There is no written summary of corrections made available for any of these violations.
15c -- Self-assessment begin date of 12/1/2022 and end date of 2/28/2023 lists citation for 141c6. There is no written summary of correction made available for this violation.
15c -- Self-assessment begin date of 1/24/2023 and end date of 2/28/2023 lists citations for 165b and 181f. There is no written summary of correction made available for these two violations.
15c -- Self-assessment begin date of 8/25/2023 and end date of 9/10/2023 lists citation for 141c3. There is no written summary of correction made available for this violation.
There was a citation for regulation 106 on the self-assessment completed on
2/28/23, but no POC was attached for this citation.
There was a citation for regulation 169a on self-assessment
completed on 9/15/23, but no POC was attached for this regulation.
There was a citation for 151a on the self-assessment completed on
9/17/23, but no POC was attached for this citation.
There were citations for regulations 141(c)6 and 165g on the self-
assessment completed on 2/27/23, but no POC was attached for these citations.
There were citations for regulations 142a and 168a on thed self-
assessment completed on 2/25/23, but there was no POC attached to the self-
assessment.
There were citations for regulations 141(c)4 and 168a on the self-
assessment completed on 2/25/23, but there was no POC attached to the self-
assessment.
There was a citation for regulation 18i on self-assessment dated 2/28/23,
but there was no POC attached for this citation.
There was a citation for regulation 166a on self-assessment completed on
9/15/23, but no POC was attached for this citation.
There were citations for regulations 106, 181a, 181f, 182a, and 183c on the West End
Avenue self-assessment completed on 2/28/23, but no POC was attached for these
citations.
There as a citation for regulation 166a on the West End Avenue self-assessment
completed on 9/15/23, but there was no POC attached for this citation. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| - Director of Residential Services provided verbal and written education/retraining to Program Specialists on 10-23-23 regarding regulation 15C that specifies the summary of corrections and attached proof that the plan of correction is completed with the self-assessments.
- Director of Residential Services met with the Instructional Technology department on 9-25-23 regarding the syncing issues of the agency's drive that maintains the summary of corrections and assessments.
- The Director of Residential uploaded the plan of corrections for the home regarding violations of citations for regulations 141b and 165b on 10-13-23.
- The Director of Residential uploaded the plan of corrections for thee home regarding citations for regulations 151a and 165g on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the e home regarding citations for regulations 166b Home on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 151a on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home on citations for regulations 141c6, 144, 165b and 142b-h (not listed as marked as violations on the scoresheet) on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 141c4, 151a, 166b on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 141c and 142a-142h on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 32r, 112a, 112b, 141a, 141c, 181c, 181f on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citation for regulation 141c6 on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the Penryn Road Home regarding citations for regulations 165b and 181f on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the Swarthmore Drive home regarding citations for regulations 141c3 on 10-13-23
- The Director of Residential uploaded the plan of corrections for the home regarding citation for regulations 106 on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citation for regulation 169a on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 141c3 on 10-13-23.
- The Director of Residential uploaded the plan of corrections for thet home regarding citations for regulations 141c6 and 165g on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 142a and 168a on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the
i home regarding citations for regulations 141c4 and 168a 10-13-23.
- The Director of Residential uploaded the plan of corrections for home citation for regulation 18i on 10-13-23.
- The Director of Residential uploaded the plan of correction for citation for 166a on 10-13-23.
- The Director of Residential uploaded the plan of corrections for the home regarding citations for regulations 106, 181a, 181f, 182a, 183c on 10-13-23.
- The Director of Residential uploaded the plan of corrections for thee home regarding citations for regulations 166a on 10-13-23. |
10/30/2023
| Implemented |
| 6400.22(d)(2) | For individual #1, the home ledger balance on 9/15/2023 was $26.19. The next entry on 9/18/23 states in the description "count" and the new balance indicated was $20.00. The ledger does not indicate that $6.19 was spent and where it was spent.
Also, the ending ledger balance for the month of August was documented as $53.04, however the beginning balance for September is documented as $48.11. There is no indication of when or where the $4.93 was spent. | (2) Disbursements made to or for the individual.
| The individual was reimbursed for both the $6.19 and the $4.93 purchase since the staff did not obtain a receipt. |
10/13/2023
| Implemented |
| 6400.22(e)(1) | For individual #1, the home ledger balance on 9/6/2023 was $1.77; then on 9/14/2023 the ledger states the balance was $56.15. The ledger does not indicate the deposit amount. In the "description" portion of the ledger, it only indicates the word "count". The amount deposited was $54.38. | 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. | The deposit amount was added to the individuals financial ledger. |
10/13/2023
| Implemented |
| 6400.62(a) | There was a locked cabinet in the upstairs bathroom and a locked room in the basement, both containing poisons; however, the key to these locks were being stored on a hook on the wall that is easily visible and accessible to the individuals.
Individual #1's most recent assessment dated 2/10/2023 does indicate that individual #1 is not safe around poisons and poisons need to be locked and inaccessible. | Poisonous materials shall be kept locked or made inaccessible to individuals. | - Director of Residential Services provided written education/retraining to Program Specialists on 10-13-23 regarding the regulation 62a referencing poisonous materials are to be locked or made inaccessible to individuals who are not safe using or around poisonous materials. An in-person training also occurred to both Program Specialists and Supervisors on 10/25/2023 for the regulation 62a referencing poisonous materials are to be locked or made inaccessible to individuals who are not safe using or around poisonous materials and were trained to ensure individuals assessments and plans are accurate regarding poisonous materials.
- Director of Residential Services trained in person both Program Specialists and Supervisors on 10/25/23 the monthly home/site checklist is to be completed accurately stating and ensuring poisonous materials are locked and made inaccessible if an individual is not safe using or around poisonous materials according to their ISP.
- Program Specialist completed an addendum to Individual #1s assessment on 10-23-23 to state the specific items that Individual #1 is safe in using and that all other poisonous materials will remain locked. In addition, Program Specialist stated in the addendum the Individual #1 is not capable of using a key to access the poisonous materials. |
10/30/2023
| Implemented |
| 6400.112(c) | The fire drill held on July 13, 2023, documented that the hypothetical location of the fire was at the Main Entrance. It also stated that the evacuation route/exit used was the front door/main entrance.
This also occurred again on the fire drill held on 12/16/2022 and 11/30/22.
The fire drill held on March 7, 2023, did not indicate where the hypothetical location of the fire was. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Management and Direct care staff were all retrained on this regulation by Director of Residential Services Leo Marcantonis on 10-5-23. The residential management will be further retrained on this regulation in an in-person training on October 25th. Training includes that the fire drill must always state what the hypothetical location of the fire is and that the smoke detector that is closest to the hypothetical location of the fire should be the smoke detector that is used. |
10/13/2023
| Implemented |
| 6400.51(b)(5) | Staff # 10 was hired on 03/30/22 and did not receive training in Job knowledge until 01/03/23. | The orientation must encompass the following areas: Job-related knowledge and skills. | - Director of Residential Services provided written training to Program Specialists, Supervisors and Human Resources staff on 10/13/2023 regarding the importance of the regulation 51b5 that each new hire receive training in job related knowledge and skills and the Job-Related Knowledge and Skills form completed for any new Residential staff's first day at the home prior to working with an individual in the Residential program and submitted to the Human Resource Department and Director of Residential within 24 hours of completion. |
10/30/2023
| Implemented |
| 6400.166(a)(11) | The medication "Levonorgestrel and Ethinyl Estradiol Tablets, USP 0.15mg/0.03mg" for individual #1 did not indicate the diagnosis or purpose of the medication on the Medication administration record (MAR). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | - Director of Residential Services provided written training to Program Specialists and Supervisors on 10/13/2023 regarding the importance of the regulation 166a11 of ensuring the diagnosis or purpose of the medication is listed on the medication record for each prescription medication of the individual. In person training regarding this regulation was also provided to Program Specialists and Supervisors on 10/25/2023 repeating the importance of ensuring the diagnosis or purpose of the medication is listed on the medication record of the individual.
- The pharmacy was contacted by the Residential Director and the diagnosis has been added to the Medication record in Quickmar for Individual #1 on 9-22-23. |
10/30/2023
| Implemented |
| 6400.166(a)(13) | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: (13) Name and initials of the person administering the medication.
The 7am dose of "450 Fluoxetine 20mg/5ml" prescribed for Mood Disorder for individual #1 did not contain the name and initials of the person administering the medication-on-Medication administration record (MAR) on 9/9/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | - Director of Residential Services provided written training all Residential staff on 10-13-23 regarding the importance of the regulation 166a13 of ensuring name and initials of the person administering the medication is on the medication record of the individual for every medication administration. An in-person training was provided to Program Specialists and Supervisors on 10/25/2023 on the importance of ensuring name and initials of the person administering the medication is on the medication record of the individual for every medication administration. This training also included a review of the Agency's Medications Errors Policy.
- This incident for Individual #1 was entered into EIM on 9-21-23 by Program Specialist, |
10/30/2023
| Implemented |