| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | There is no September 2017 financial leger for individual #2. It was unable to be located. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | See paper copy. |
11/15/2017
| Implemented |
| 6400.44(b)(10) | No monthly documentation of individual #2 participation and progress towards her outcomes were reviewed, signed, and dated by the program specialist. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes. | NHS recognizes that Individual #2's ISP monthly reviews cannot be corrected, reviewed, signed and dated through October 2017, as the available data is insufficient.
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.44(b)(10) specific to the responsibility to review, sign and date monthly documentation of individual's participation and progress towards outcomes. Team Supervisors were further trained in the responsibility to assure monthly documentation is effective and available to the Program Specialists for review and signature. (Program Specialist Training Attachment #2, and Team Supervisor Training Attachment #7).
To monitor compliance, reviews of individual record detail- including participation and progress in outcomes-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample completed Supervision form attached #5). |
11/15/2017
| Implemented |
| 6400.44(b)(18) | Individual #2 program specialist did not coordinate the training of her BSP written June 2017. Not all staff are trained on this plan. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | All staff supporting Individual #2 have been trained on the behavior plan, and the plan has been fully implemented effective 10/25/2017. (Individual #2 Team BSP Training Attachment #19).
To prevent a recurrence of this violation, all Residential Program Specialists and Team Supervisors have been retrained on regulation 6400.188(a) including the responsibility to assure all staff are trained and effectively implement all supports, including behavior supports, for every individual assigned to their care. (Program Specialist Training Attachment #2 and Team Supervisor Training Attachment #7).
Additionally, all Direct Support Professionals (DSPs) will be trained on accurate and thorough documentation requirements, including clear and measurable documentation on outcomes, implementation of support plans, and other required information on the Daily documentation forms. (Sample DSP Training Attachment #8) The remainder of the DSP training sheets will be submitted by 12/15/17.
To document compliance to this requirement, the Program Specialists or the NHS BSP trains all new hires on Behavior Support Plans during new hire orientation, assuring they have the training before working with the individuals, as well as assuring all staff are trained on any new behavior plans and updates to existing plans. (Sample New Hire Documentation Attachment #20, Individual #2 Team, BSP Training Attachment #19).
The BSP (11/13/17) and the Program Specialists (11/8/17) have been trained on this responsibility. (Program Specialist Training Attachment #2, BSP Training Attachment #21)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample Monthly Supervision attachment # 5) |
12/15/2017
| Implemented |
| 6400.67(a) | The carpet in the dining and living room is dirty and stained. | Floors, walls, ceilings and other surfaces shall be in good repair. | The carpet in the dining and living room is on capital list of items to replace. Fluss Flooring is going to do the carpet installation on 1/4/18-1/5/18. (Email confirmation, Attachment #31)
To prevent a reoccurrence, Team supervisors were retrained on 11/9/17 on regulation 6400.67(a) and the responsibility to ensure that floors, walls, ceilings and other surfaces are in good repair. It is the responsibility of all staff to immediately report any hazardous and the responsibility of the Team Supervisor to report immediately to the maintenance department through the Skyline Database and handled with priority. The DSPs will be trained in this responsibility.(Team Supervisors Training Attachment #7, Sample DSP Training Attachment #8) The remainder of the DSP training sheets will be submitted by 12/15/17.
To ensure compliance to this requirement, the Team Supervisors are responsible to do weekly physical site reviews using a Compliance Checklist documenting a physical site check. This review process will be monitored by the assigned Administrator, who will sign off on the Compliance Checklist form. The Administrator has been trained in this responsibility 11/14/17. (Administrator Training attachment #13) (Completed Compliance Checklist Sample Attachment #18). |
12/15/2017
| Implemented |
| 6400.76(a) | The office chair that is in the dining area is falling apart. The stuffing in the arms are out and the material is ripped. REPEAT. | Furniture and equipment shall be nonhazardous, clean and sturdy. | NHS Capital region acknowledges the serious nature of a repeat violation. The chair in question had been moved out of the area at an earlier date, and without permission was moved back. The office chair has now been removed from the home. (Photo of new chair, attachment #30)
To prevent a reoccurrence, Team supervisors were retrained on 11/9/17 on regulation 6400.76(a) and the responsibility to ensure the furniture and equipment is nonhazardous, clean and sturdy. It is the responsibility of all staff to immediately report any hazardous furniture or equipment and the responsibility of the Team Supervisor to report immediately to the maintenance department through the Skyline Database and handled with priority (Team Supervisors Training Attachment #7 DSP Training Attachment #8).
To ensure compliance to this requirement, the Team Supervisors are responsible to do weekly physical site reviews using a Compliance Checklist documenting a physical site check. This review process will be monitored by the assigned Administrator, who will sign off on the Compliance Checklist form. The Administrator has been trained in this responsibility 11/14/17. (Administrator Training attachment #14) (Completed Compliance Checklist Review Sample Attachment #18). |
11/15/2017
| Implemented |
| 6400.104 | The 4/1/2017 fire letter to the fire department list all three individuals that reside in the home only requiring verbal prompts to evacuate; however all fire drills reviewed during the inspection state that individual #3 requiring physical 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.
| The fire letter to the fire department has been edited to include accurate assistance needs for all individuals in this home, and the edited letter has been sent to the local fire department. (Updated letter Attachment #27, copy of addressed and stamped envelope to the local fire department Attachment #28)
To assure this violation does not recur, the Program Specialist (11/8/17) and Administrative Operations Liaison (11/14/17) have been trained on the need to fully review and assess evacuation and assistance needs for all individuals served. (Program Specialist Training Attachment #2 and Administrative Operations Liaison Training Attachment #14)
Additionally, all letters to the fire departments have been reviewed, and corrected and sent as necessary to bring all homes into compliance. (Verification of audit of all letters and correction as needed Attachment #29)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists and Program Manager. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(11) | Individual #2 psychological evaluation completed on 7/6/2017 was not a part of her 9/27/2017 assessment. | The assessment must include the following information: Psychological evaluations, if applicable. | The 9/27/17 assessment of individual #2 has been updated to include the psychological evaluation completed on 7/6/2017. (Individual assessment of psychological evaluation, Attachment #25, page 8 )
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including current psychological testing information-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(12) | The recommendations for individual #2 noted in her 9/27/2017 assessment was the same as the previous assessment. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The assessment dated 9/27/2017 was updated to include current recommendations for Individual #2. (Individual assessment of current recommendations, Attachment # 25 page 18)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including recommendations per the assessment-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(13)(i) | Individual #2 assessment 9/27/2017 did not update her recent hospitalization in July 2017. | 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.
| The assessment for Individual #2 has been edited to include the most recent hospital stay in July 2017. (Individual assessment of recent hospitalizations, Attachment # 25, pages 2-8)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including all hospitalization information-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(13)(iii) | Individual #2 assessment 9/27/2017 no progress and growth. Same as previous year. | 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. | The assessment for Individual #2 has been edited to clarify progress over the last 365 calendar days and the current level in activities of residential living. (Individual Assessment of activities of residential living, Attachment #25, pages 9-11)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including progress/current level in residential activities-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2 assessment 9/27/2017 no progress and growth. Same as previous year. | 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. | The assessment for Individual #2 has been edited to clarify progress over the last 365 calendar days and the current level in personal adjustment. (Individual Assessment of personal adjustment, Attachment #25, pages 15-17)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including current level in personal adjustment-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #2 assessment 9/27/2017 no progress and growth. Same as previous year. | 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. | The assessment for Individual #2 has been edited to clarify progress over the last 365 calendar days and the current level in socialization. (Individual Assessment of socialization, Attachment #25, pages 12-13)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including current level in socialization-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample |
11/15/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2 assessment 9/27/2017 no progress and growth. Same as previous year. | 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. | The assessment for Individual #2 has been edited to clarify progress over the last 365 calendar days and the current level in recreation. (Individual Assessment of recreation, Attachment #25, pages 12-13)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including current level in socialization-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.181(e)(13)(ix) | Individual #2 assessment 9/27/2017 no progress and growth. Same as previous year. | 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. | The assessment for Individual #2 has been edited to clarify progress over the last 365 calendar days and the current level in community-integration. (Individual Assessment of community-integration, Attachment #25, pages 12-13)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.181a-181(e)(14), detailing all areas required by regulation in the assessment and the PS responsibility that the ISP is accurate and includes assessment of all areas required. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including progress and current level in community integration-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.183(4) | Individual #2 ISP updated 9/25/2017 does not state the amount of time she can be alone in a vehicle without supervision. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | The current assessment for individual #2 indicated that she could be left alone in a vehicle for up to 10 minutes. The assigned Program Specialist requested an update to the ISP for Individual #2 that includes the amount of time she can be alone in the vehicle without supervision. (Assessment for alone time in the vehicle, Attachment #23)(ISP Update Request Attachment #24)
To prevent a recurrence of this violation, All Residential Program Specialists were retrained on 11/8/17 in 6400.183(4) and their responsibility to ensure all unsupervised time is assessed and planned for according to the 6400 regulations. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including time a person may be left alone-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.186(c)(2) | Individual #2 outcomes Independence/Healthy Lifestyle has not changed over the past review year; however the ISP reviews do not include the details of participation and progress of her expected outcomes. The reviews do not give any updates to the outcomes; only states she completed the goal x amount of times. Individual #2 1/25/2017 ISP review does not review her Healthy Lifestyle outcome. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | NHS Capital Region acknowledges that Individual #2's ISP reviews already on file cannot be corrected, as the data and information available is insufficient.
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.186©(2) and their responsibility to include a review of each section of the ISP, including details of participation and progress and updates of all listed outcomes and support plans (Program Specialist Training Attachment #2)
Additionally, all Direct Support Professionals (DSPs) will be trained on accurate and thorough documentation requirements, including clear and measurable documentation on outcomes, implementation of support plans, and other required information on the Daily documentation forms. (Sample DSP Training Attachment #8) The remainder of the DSP training sheets will be submitted by 12/15/17
The Team Supervisor has also been trained on 11/9/17 on the responsibility to monitor and mentor effective documentation of the DSPs through onsite weekly monitoring. (Team Supervisor Training Attachment #7)
To monitor compliance, reviews of individual record detail- including a review of all sections of the ISP-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the residential Program Specialists. (Sample completed Supervision form attached #5) |
12/15/2017
| Implemented |
| 6400.186(d) | Individual #2 Behavioral Support Specialist was not sent any ISP reviews over the review year. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Individual #2 Behavioral Support Specialist has been sent the most recent ISP review for individual #2. (Sent E Mail Verification Attached #22)
To prevent a recurrence of this violation, the NHS Director of Program Assistance conducted a thorough training for all Residential Program Specialists on 11/8/17 on regulation 6400.186(d), and their responsibility to provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.(Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including providing ISP reviews to all team members-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.186(e) | The Option to Decline was not offered to individual #2 Behavioral Specialist. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Individual #2 Behavioral Support Specialist has been offered the Option to Decline the ISP Documentation. (Sent Email verifying Declination Option Attachment #22)
To prevent a recurrence of this violation, All Residential Program Specialists were retrained on 11/8/17 in their responsibility to ensure all planning processes and documents are effectively completed and secured in the permanent record, to include the NHS document that offers declination of ISP updates and reviews to all eligible team members. Additionally, the training included discussion that ALL team members must indicate their acceptance or declination of updates, including a process for those not present at the planning meeting. (Program Specialist Training Attachment #2)
To monitor compliance, reviews of individual record detail- including offering the option to decline ISP reviews to team members-will be completed by the auditing team, which is comprised of the Program Specialists, IDD Director and other NHS support staff during quarterly quality audits of 25% of the residential records . Next quarterly audit scheduled for December 2017. (Completed sample Audit Attached #4)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample completed Supervision form attached #5) |
11/15/2017
| Implemented |
| 6400.188(a) | Individual #2 had a behavioral plan in place since June 2017 completed by the ARC of Dauphin CO. The plan has not been implemented as written. All staff who support individual #2 were not utilizing the plan. | The residential home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | All staff supporting Individual #2 have been trained on the behavior plan, and the plan has been fully implemented effective 10/25/2017. (Individual #2 Team BSP Training Attachment #19).
To prevent a recurrence of this violation, all Residential Program Specialists and Team Supervisors have been retrained on regulation 6400.188(a) including the responsibility to assure all staff are trained and effectively implement all supports, including behavior supports, for every individual assigned to their care. (Program Specialist Training Attachment #2 and Team Supervisor Training Attachment #7).
Additionally, all Direct Support Professionals (DSPs) will be trained on accurate and thorough documentation requirements, including clear and measurable documentation on outcomes, implementation of support plans, and other required information on the Daily documentation forms. (Sample DSP Training Attachment #8) The remainder of the DSP training sheets will be submitted by 12/15/17
To document compliance to this requirement, the Program Specialists or the NHS BSP trains all new hires on Behavior Support Plans during new hire orientation, assuring they have the training before working with the individuals, as well as assuring all staff are trained on any new behavior plans and updates to existing plans. (Sample New Hire Documentation Attachment #20, Individual #2 Team, BSP Training Attachment #19).
The BSP (11/13/17) and the Program Specialists (11/8/17) have been trained on this responsibility. (Program Specialist Training Attachment #2, BSP Training Attachment #21)
Additionally, the IDD Regional Director will conduct random review of the necessary content of program records during monthly supervision with the Residential Program Specialists. (Sample completed Supervision form attached #5). |
12/15/2017
| Implemented |