Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235001 Renewal 11/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)(.141d) Individual #1 had their TB Test read on 3/26/23 by a Medical Service Technician.(.141d) - Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant.The Licensed Physician Assistant typically has, in the past, completed the biennial TB noted on the annual physical form, however the Medical Service Technician under the guidance of the CNP, read and initialed the TB results on the annual physical form completed on 3/26/23. Going forward, the Program Manager will ensure the TB is read and signed by the Licensed Physician's Assistant, Physician or Certified Nurse Practitioner. This was corrected at the time of the inspection and the correction was sent to the inspector on 12/1/23. 01/31/2024 Implemented
6400.141(b)(repeat from 1/17/23) The doctor did not date the most recent physical completed on 3/13/23 for Individual #1.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. During the annual physical that occurred on 3/13/23 the PCP did not date the physical form or print their name. Going forward the Program Manager will ensure the PCP has dated and printed their name on the annual physical form prior to leaving the physician's office. This was corrected at the time of the inspection and the corrected physical form was sent to the inspector on 12/1/23. 01/31/2024 Implemented
6400.143(a)(repeat from 1/17/23) Individual #1's doctor prescribed them to be on a 1500 calorie diet. From January 2023 to the present Individual #1 ate more than 1500 calories in a day a total of 41 times. There is no documentation that Individual #1 was educated on the importance of following the dietary recommendations.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual #1 has a calorie restricted diet which is tracked in Therap under intake and elimination. Program Specialists document the monthly caloric intake in quarterly reports which are reviewed with, and a copy given to, the individual however no documentation of Individual #1 having received education of the importance of following her diet was documented on the quarterly report. Going forward, the Program Specialist will provide the individual with education on the importance of following the prescribed diet and document the education provided on the quarterly report. 01/31/2024 Implemented
6400.211(b)(3)Individual #1's demographic information does not include the name, address, and phone number of who to call for medical consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Program Managers and Program Specialists will be trained on the new format for the Demographic sheet by the Quality Assurance Director by 1.22.2024. It will include a section for Medical Consent. This addition does not negate the Emergency Medical form located in all individual's charts; however, the person(s) listed must be the same. The updated forms are to be sent to the Quality Assurance Department by 1.31.2024 for review. 01/31/2024 Implemented
6400.165(c)(repeat from 1/17/23) Individual #1 is to receive two Senna Docusate Sodium Tablets at bedtime if they do not have a bowel movement for three days. Individual #1 did not have a bowel movement on 7/23/23, 7/24/23, or 7/25/23. They were not administered their Senna Docusate Sodium at bedtime as prescribed.A prescription medication shall be administered as prescribed.Program Managers and their supervisory staff are required to review bowel movements daily. T-Logs, along with Intake and Elimination will be utilized to track and to inform all staff of pending need for intervention when 72 hours have passed without a bowel movement. 01/31/2024 Implemented
6400.165(g)The reason for prescribing the Topiramate was not documented on Individual #1's quarterly psych medication forms.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.Program Specialists and Program Managers are required to review the psychiatric medical appointment sheet prior to attending the scheduled appointment. The diagnosis for topiramate was missed during these reviews. Going forward, the psychiatric medical appointment sheet will be sent to the Behavior Supports Specialist for review, 2 weeks prior to the appointment occurring. 01/31/2024 Implemented
6400.166(a)(2)(repeat from 1/17/23) Individual #1's November MAR did not have the prescriber listed for the current Trospium medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.During review of the MAR it was discovered that the prescribing physician was not listed on the MAR for Tropsium Chloride. The Program Manager corrected this at the time of the inspection and documentation was sent to the inspector on 12/1/23, proving the correction occurred. 01/31/2024 Implemented
6400.166(b)From January to the present there were 153 medication administrations that were not logged immediately.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Quality Assurance has been conducting retraining at all the CLAs regarding the requirement to mark the medication administration as completed prior to the end of the allotted window. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for missing the window to document will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. 01/31/2024 Implemented
6400.182(c)Individual #1's most recent ISP completed on 9/19/23 indicates that the Individual does not have a restrictive procedure in place. However, Individual #1 does have a restrictive procedure.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Individual #1's ISP includes the restrictive procedures that are in place. The restrictive box on the ISP should have been marked but the non-restrictive box was checked by the SC indicating that the plans were non-restrictive. This was not seen by the Program Specialist during review of the ISP. 01/31/2024 Implemented
6400.183(a)(2)Individual #1's next of kin was not invited to the ISP team meeting held on 6/9/23.The individual plan shall be developed by an interdisciplinary team, including the following: Persons designated by the individual.The ISP invitation sent by the SC did not include the designated next of kin. Going forward, the Program Specialist will notify the SC if the entire team is not included on the invitation letter. 01/31/2024 Implemented
6400.207(5)(I)Individual #1 is currently using bedrails and has not completed the required procedure to use bedrails.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care.The regulatory process for use of bedrails was not followed and bedrails were in place at the time of the inspection. The bedrails were removed at the time of the inspection and are no longer in use. 01/31/2024 Implemented
SIN-00233605 Unannounced Monitoring 10/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(2)Individual #3 moved into the home in December 2009. Individual #3 has a history of voyeurism, fetishism, and paraphalia. Individual #3 was incarcerated for 7 years for inappropriate contact with young females, breaking and entering, and stealing women's undergarments. Individual #1 was moved into the home in July 2010. This individual should not have been moved into the home with Individual #3's known history. Individual #2 moved into the home on 4/19/22. Individual #2 likes a calm and quiet environment and has a history of aggressive behavior. Individual #1 also has a history of aggressive behavior and physical and verbal abuse. These individuals should not be in the same home as their needs cannot be met within the same home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Admission and discharge of individuals. Individual#1, individual#2 and individual#3 were moved into the home after it was decided by their respective teams, which included individual#1, individual#2, individual#3, the SC unit and family members. Individual#3 has not exhibited any of the past history cited in the above paragraph during his time with VCS. VCS has implemented an admission process that involves a thorough vetting of ISP's and individuals that are admitted into the homes. VCS will continue to monitor the admission process as well as provide the safest environment possible for all the individuals we serve including those with very diverse and difficult backgrounds. The CEO will continue to be a part of the admission process. 12/08/2023 Implemented
6400.43(b)(3)Individual #1, #2, and #3 all reside in the same home. On 10/19/23, Individual #1 reported that Individual #2 and #3 had unwanted sexual contact with Individual #1. There was no separation of Individual #1, the victim, from their targets until 10/23/23, when Individual #2 and Individual #3 were moved to a hotel while the investigation was ongoing.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Individual #1 made an allegation of sexual abuse during a routine medical appointment. The DSP that heard the allegation reported to on call as soon as they returned to the CLA home. An investigation was started immediately. Individual #1, #2 and #3 were not immediately moved to separate housing. The CEO will be retrained by the Chief Administrative Officer on following Incident Management Protocol for sexual abuse allegations. This training will be completed by 12/8/2023. 12/08/2023 Implemented
6400.18(f)Individual #1, #2, and #3 all reside in the same home. On 10/19/23, Individual #1 reported that Individual #2 and #3 had unwanted sexual contact with Individual #1. There was no separation of Individual #1, the victim, from the targets until 10/23/23, when Individual #2 and Individual #3 were moved to a hotel while the investigation was ongoing.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.Individual #1 made an allegation of sexual abuse during a routine medical appointment. The DSP that heard the allegation reported to on call as soon as they returned to the CLA home. An investigation was started immediately. Individual #1, #2 and #3 were not immediately moved to separate housing. The Quality Management Director will be retrained by the Chief Administrative Officer on following Incident Management Protocol for sexual abuse allegations. This training will be completed by 12/8/2023. 12/08/2023 Implemented
6400.20(a)(1)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. Five of these incidents involved Individual #2, two of which were physical and 3 were psychological abuse. The other 11 psychological abuse incidents involved Individual #3. With each incident, there was not an analysis to determine the cause of the incident.The home shall complete the following for each confirmed incident: Analysis to determine the cause of the incident.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the behavior supports specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the HRC committee, trained by the behavior supports specialist and implemented by the Direct Support Specialists. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the behavior supports specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the behavior supports specialist and implemented by the Direct Supports Specialists. The Quality Management Director will be trained by the Chief Administrative Officer, on including the analysis of the incident in the EIM as well as the relevent outcome of the plans that were developed and implemented for prevention of future incidents by 12/08/2023. 12/08/2023 Implemented
6400.20(a)(2)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. In 14 of these incidents, the corrective action was to offer the victim emotional support and counseling the target in appropriate behaviors. The corrective action for 2 of the incidents indicated that the behavior plans for both individuals would continue to be implemented. There was to be a safety plan implemented on 6/9/23 for Individual #1 that included a contingent separation after a 5/21/23 psychological abuse incident, however, there have been 4 more incidents since this implementation, and it is unclear if the plan has been implemented in the home.The home shall complete the following for each confirmed incident: Corrective action, if indicated.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the Behavior Supports Specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the Human Rights Committee, trained by the Behavior Supports Specialist and implemented by the Direct Support Professionals. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the Behavior Supports Specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the Behavior Supports Specialist and implemented by the Direct Supports Professionals. The contigent separation plan was not utilized by the Direct Support Professionals as the 4 incidents that occurred after implementation were able to be mitigated using redirection.The Quality Management Director will be trained by the Chief Administrative Officer on including the corrective action and all relevant data surrounding plans implemented for the individuals to mitigate the individual to individual abuse incident in the EIM report by 12/08/2023 12/08/2023 Implemented
6400.20(a)(3)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. Five of these incidents involved Individual #2, two of which were physical and 3 were psychological abuse. The other 11 psychological abuse incidents involved Individual #3. There has not been a strategy implemented to address the potential risks to the individual.The home shall complete the following for each confirmed incident: A strategy to address the potential risks to the individual.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the Behavior Supports Specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the Human Rights Committee, trained by the Behavior Supports Specialist and implemented by the Direct Support Professionals. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the Behavior Supports Specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the Behavior Supports Specialist and implemented by the Direct Supports Professionals .A safety plan was developed and implemented for individual#1 to address potential risks identified during analysis of the confirmed individual to individual incidents. The safety plan was not implemented until 6/9/2023. A risk assessment will be utilized by the incident management team for all confirmed individual to individual abuse incidents. The Quality Management Director will be trained on the use of the risk assessment by the Chief Administrative Officer by 1/31/2024. 01/31/2024 Implemented
6400.20(c)(1)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. Five of these incidents involved Individual #2, two of which were physical and 3 were psychological abuse. The other 11 psychological abuse incidents involved Individual #3. There have been no measures identified or implemented to reduce the number of individual-to-individual abuse incidents in the home.The home shall identify and implement preventive measures to reduce: The number of incidents.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the Behavior Supports Specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the Human Rights Committee, trained by the Behavior Supports Specialist and implemented by the Direct Support Professionals. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the Behavior Supports Specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the Behavior Supports Specialist and implemented by the Direct Supports Professionals. A safety plan was developed and implemented for individual#1 to address potential risks identified during analysis of the confirmed individual to individual incidents. The safety plan was not implemented until 6/9/2023. The use of support plans, behavior plans or safety plans did not reduce the number of incidents. A team meeting was held on 11/9/2023 to discuss with individual#1 the option of moving to a home with no roommates. Individual#1 has chosen to move. A home has been secured and the process to move individual#1 has been started. 01/31/2024 Implemented
6400.20(c)(2)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. Five of these incidents involved Individual #2, two of which were physical and 3 were psychological abuse. The other 11 psychological abuse incidents involved Individual #3. There have been no measures identified or implemented to reduce the severity of the risk associated with the incidents.The home shall identify and implement preventive measures to reduce: The severity of the risks associated with the incident.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the Behavior Supports Specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the Human Rights Committee, trained by the Behavior Supports Specialist and implemented by the Direct Support Professionals. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the Behavior Supports Specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the Behavior Supports Specialist and implemented by the Direct Supports Professionals. A safety plan was developed and implemented for individual#1 to address potential risks identified during analysis of the confirmed individual to individual incidents. The safety plan was not implemented until 6/9/2023. The use of support plans, behavior plans or safety plans did not reduce the number of incidents. A team meeting was held on 11/9/2023 to discuss with individual#1 the option of moving to a home with no roommates. Individual#1 has chosen to move. A home has been secured and the process to move individual#1 has been started. 01/31/2024 Implemented
6400.20(c)(3)From 10/1/22 through 10/19/23, there were a total of 16 Individual to Individual abuse incidents between Individual #1 and Individuals #2 and #3. Five of these incidents involved Individual #2, two of which were physical and 3 were psychological abuse. The other 11 psychological abuse incidents involved Individual #3. There have been no measures identified or implemented to reduce the likelihood of these incidents occurring in the home.The home shall identify and implement preventive measures to reduce: The likelihood of an incident recurring.An analysis of each individual to individual abuse incident was completed at the time of the occurrence of the incident (see attachment #1, #2). This information was given to the behavior supports specialist. It was determined the incidents between individual#1 and individual#3 were occurring surrounding phone usage. Individual #1 was placed on a phone plan which was approved by the HRC committee, trained by the behavior supports specialist and implemented by the Direct Support Professionals. An analysis of the confirmed incidents between individual#1 and individual#2 was completed at the time of occurence of the incident(see attachment#1,#2). This information was given to the behavior supports specialist. It was determined that individual#1 would utilize a contingent separation plan which was trained by the Behavior Supports Specialist and implemented by the Direct Supports Professionals. An assessment of the likelihood of an incident recurring was not included in the data analysis that was completed for each confirmed incident. The incident management team will develop an assessment tool to assess the likelihood of an recurrance of a confirmed individual to individual abuse incident. This will be added to the current analysis tool. The tool will be developed, trained and implemented by 1/31/2024. 01/31/2024 Implemented
6400.32(c)Individual #1, #2, and #3 all reside in the same home. On 10/19/23, Individual #1 reported that Individual #2 and #3 had unwanted sexual contact with Individual #1. There was no separation of Individual #1, the victim, from their targets until 10/23/23, when Individual #2 and Individual #3 were moved to a hotel while the investigation was ongoing. This failure to protect the health and safety of Individual #1 created a situation conducive to further abuse.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Individual #1 made an allegation of sexual abuse during a routine medical appointment. The DSP that heard the allegation reported to on call as soon as they returned to the CLA home. An investigation was started immediately. Individual #1, #2 and #3 were not immediately moved to separate housing. The Quality Management Director will be retrained by the Chief Administrative Officer on following Incident Management Protocol for sexual abuse allegations. This training will be completed by 12/8/2023. 12/08/2023 Implemented
SIN-00182097 Renewal 01/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144At the time of the inspection, Individual #1's PRN medication Cyclobenzaprine, used for muscle spasms, was expired. There was no unexpired Cyclobenzaprine at the home in case the Individual needed this medication.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. The PRN medication has been received by the home. Program Managers were trained on regulation 6400.144 by the Director of Quality Assurance and Training on 03/09/21 (#6). The outline and attendance record are submitted for review. Program Managers reviewed all PRNs for persons we serve and ensured none were expired. Program Managers were trained on the responsibility to verify the expiration date on each PRN medication monthly, when checking in medication replenishment shipment. Any PRN that would expire in two months, an order form is sent to the pharmacy for replenishment at the next scheduled delivery. The Program Managers will place a copy of the order form in the MAR book. Monitoring of the PRNs will be completed by the Quality Assurance & Training Associate during biannual inspections. 03/09/2021 Implemented
6400.163(h)At the time of the inspection, Individual #1's PRN medication Cyclobenzaprine had an expiration date of 1/9/2021. This medication has not been disposed of properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The PRN medication has been properly disposed. Program Managers were trained on regulation 6400.144 by the Director of Quality Assurance and Training on 03/09/21.(#6) The outline and attendance record are submitted for review. Program Managers reviewed all PRNs for persons we serve and ensured none were expired. Program Managers were trained on the responsibility to verify the expiration date on each PRN medication monthly, when checking in medication replenishment shipment. Expired PRNs are disposed of immediately by sending unused expired medication to the pharmacy for proper disposal. PRN medications are pulled from the persons locked medication drawer and placed in the locked tote with a disposal form. The tote is returned to the pharmacy. The Program Managers will place a copy of the disposal form in the MAR book. Monitoring of the PRNs will be completed by the Quality Assurance & Training Associate during biannual inspections. 03/09/2021 Implemented
6400.165(g)Individual #1 had a medication review on 3/16/20. Her next review was not until 7/1/20.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.Program Specialists have been trained on regulation 6400.165(g) by the Director of Quality Assurance & Training on 3/09/21. The outline and attendance record are submitted for review. (#6) The medication review date was changed to align with the Psychiatrists signature and date. This appointment was completed via Telehealth and the medical review form was sent to the Psychiatrists office for signature. Program Specialists were trained on reviewing all dates to ensure they are accurate. Any discrepancy must be addressed immediately. Program Specialists may request a summary of the appointment and attach to the medical review form, as long as there is an electronic signature. Program Specialists have reviewed all medical appointment forms which were conducted by Telehealth to ensure accuracy. Monitoring will be completed by the Quality Assurance and Training Associate during biannual inspections, reviewing the dates to ensure 90 or less days are between medication reviews. 03/09/2021 Implemented
6400.166(a)(2)There is no prescriber name listed for the following medications on Individual #1's medication administration record: Clearlax, Memantine, Vitamin D3, Vitamin B12, Trospium Chloride, Pantoprazole, Metamucil, Lisinopril, Topiramate, Quetiapine, Divalproex, Trazodone, Nitrofuantoin, Desitin, Clonazepam, Neudrexta, Lactulose, Calcium, Medroxyprogesterone, Cetirizine, Cephalexin, Cefdinir, Fluticasone, Mirtazapine, Cipro, Amoxicillan, Ketoconazole, A & D Ointment, Coleman Insect Repellant, Coppertone sport, Bisacodyl, Milk of Magnesia, Aller-Chlor, Ondanstron, Loperamide, Triple Antibiotic, Calcium Antacid, Pain Relief PM, Tussin, Keri Orig Moist Therapy, Phenaseptic, Ibuprofen, Apap, Halls, Cyclobenzaprine, Banana Boat Sport, Senna, Kaopectate.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Program Managers have been trained on regulation 6400.166(a)(2) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance record are submitted for review.(#7) Starting April 2021, all MARs will list all the names of the prescribers on each page of the MAR. Program Managers will submit April 2021 MAR to the assigned Program Specialist for review. The Program Specialist will send an email to the Operations Director by 4/20/21 stating this review has been completed. To ensure no further infractions occur, the Quality Assurance & Training Associate will review the MARs for prescribers names during biannual inspections. 03/09/2021 Implemented
6400.166(a)(11)There is no diagnosis or purpose listed for the following medications on Individual #1's medication administration record: Clearlax, Memantine, Vitamin D3, Vitamin B12, Trospium Chloride, Pantoprazole, Metamucil, Lisinopril, Topiramate, Quetiapine, Divalproex, Trazodone, Nitrofuantoin, Desitin, Clonazepam, Neudrexta, Lactulose, Calcium, Medroxyprogesterone, Cetirizine, Cephalexin, Cefdinir, Fluticasone, Mirtazapine, Cipro, Amoxicillan.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 Quality Assurance & Training reviewed the MARs and requested technical support from the surveyor. With the information given, the Director of Quality Assurance & Training met with Client Services Manager at Health Direct, the pharmacy utilized by Valley Community Services, on February 24, 2021. This meeting was to ensure that the diagnosis or purpose of the medication could be added to the MARs with each individual medication. This would replace the current listing of all diagnoses on the MARs. . Program Managers, Operations Directors were trained on regulation 6400.166(a)(11) by the Director of Quality Assurance & Training on 03/09/21 (#22). Program Managers will train all current medication administrators on the correct process of adding a new or time-limited medication into the MAR, which will include the diagnosis or purpose of the medication. As of April 2021, all MARs will list all the diagnosis or purpose of the medication with the medication. Program Managers will submit the completed April 2021 MAR to the Quality Assurance department prior to 05/05/21. To ensure no further infractions occur, the Quality Assurance & Training Associate will review the MARs for diagnosis or purpose of medication during biannual inspections. 05/05/2021 Implemented
6400.181(f)Individual #1's 2020 assessment was sent to the team on 3/11/20. Her ISP meeting was conducted on 3/19/20.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialists were trained on regulation 6400.181(f) by the Director of Quality Assurance & Training on 03/09/21.(#10) The outline and attendance record are submitted for review. Each Program Specialist is responsible to ensure no Annual ISP meeting is scheduled earlier than 30 days past the date the assessment was sent to the team. When Supports Coordinators request meetings prior to the 30-days, these meetings will be considered a critical revision. The Annual Plan Meeting will continue to be scheduled 90-60 days prior to the Annual Review Date, ensuring compliance with regulation 6400.181(f). To ensure no further infractions occur, Program Specialists will send e-mails to the Operations Director designating the schedule Annual Plan meeting with the sent date of the assessment, starting 03/10/21 and ending 06/30/21. The Quality Assurance & Training Associate will monitor by reviewing the Assessment and Annual Plan meeting date to ensure compliance. 03/09/2021 Implemented
SIN-00117323 Renewal 08/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The 4/22/17 fire drill log did not indicate which exit route was used.Alternate exit routes shall be used during fire drills. VCS will ensure alternate exit routes are used during fire drills. The QA director retrained the program managers on Fire Drills and form completion on 09/14/2017. The sign in sheet, outline, VCS¿ Record of Fire Drill and Fire Equipment check, and annual fire drill schedule is attached. (#43) Program managers submitted their September 2017 form to the QA Department for review of accuracy. These fire drills are attached. (#44) To ensure no further infractions occur, the operations director will review all fire drills starting October 1, 2017 forward. If a drill is non-compliant, the program manager will be required to complete another drill prior to the end of the month to ensure compliance. 10/09/2017 Implemented
6400.141(c)(6)Individual #1's 3/22/17 tuberculin skin testing was completed late. The previous testing was completed on 2/19/15.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. VCS will ensure the physical examination includes tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older. Program managers were retrained on completion of the annual physical and the timeline of all of the required examinations on 9/14/2017. The sign in sheet,(#39) and outline, and example form are attached. (#14) The program manager at the Stewart location will submit all required appointment dates and completed documentation to the operations director starting 10/01/2017 and ending 12/31/2017. To ensure no further infractions occur, the operations director and QA department will verify all required examinations are within the time frame for a sample of individuals each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. 10/09/2017 Implemented
6400.141(c)(7)Individual #1's 6/29/17 gynecological exam was completed late. The previous exam was completed on 4/11/16.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. VCS will ensure the physical examination including gynecological examination with a breast examination and Pap test for women 18 years of age or older. Program managers were retrained on completion of the annual physical and the timeline of all of the required examinations on 9/14/2017. The sign in sheet (#40), outline, and example form are attached (#14). The program manager at the Stewart location will submit all required appointment dates and completed documentation to the operations director starting 10/01/2017 and ending 12/31/2017. To ensure no further infractions occur, the operations director and QA department will verify all required examinations are within the time frame for a sample of individuals each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. 10/09/2017 Implemented
6400.141(c)(8)There was no record of Individual #1 receiving a mammogram in the past 2 years. The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. VCS will ensure the physical examination includes a mammogram for women at least every 2 years for women 40 through 49 years of age. Individual #1 received her mammogram 08/25/2017 and results were obtain, which are attached.(#41) Program managers were retrained on completion of the annual physical and the timeline of all of the required examinations on 9/14/2017. The sign in sheet, outline, and example form are attached. (#42) The program manager at the Stewart location will submit all required appointment dates and completed documentation to the operations director starting 10/01/2017 and ending 12/31/2017. To ensure no further infractions occur, the operations director and QA department will verify all required examinations are within the time frame for a sample of individuals each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. 10/09/2017 Implemented
6400.144REPEATED VIOLATION - 8/31/16, 7/19/16. On 11/22/16, Individual #1 did not receive the prescribed dosage of Benefiber. Benefiber was not present in the home.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. VCS will ensure health services that are planned or prescribed for the individual is arranged for or provided. The QA Director retrained the program managers on their respective job duties required to complete medication shipment verification on 9/28/2017. The sign in sheet and outline are attached. (#38) Every medication administrator at the Stewart CLA have attended a medication administration refresher, which follows the Hear, See, Do format with a post-test to ensure competence. Training was completed on 10/02/2017. Sign in sheet, outline, and training packet are attached. (#35) All VCS medication administrators are required to attend this course during October 2017. To ensure no further infractions occur, the operations director and QA department will verify the medications on hand for a sample of individuals each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. 10/31/2017 Implemented
6400.163(c)Individual #1's 8/2/17, 5/18/17, 3/23/17, and 2/8/17 psychiatric medication reviews did not include the reason for prescribing the medication. The 8/2/17 medication review did not include the need to continue the medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.VCS will ensure psychiatric medication reviews include the reason for prescribing the medication, along with an accurate listing of all medications and correct doses. The QA Director retrained the program managers and program specialists on their respective job duties required to complete the Psychiatric Medication Review form on 9/14/2017. The sign in sheet, outline, and new form are attached. (#11) Program managers were required to submit the new form completed for each of the individuals they are assigned for approval to the QA Department. The program specialists now utilize the form and submit to the incident management coordinator for approval prior to appointment. Each of the program specialists have submitted a completed form, which are attached. (#12) To ensure no further infractions occur, the operations director and QA department will review a sample of Psychiatric Medication Review form each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers and program specialists on an ongoing basis. 10/09/2017 Implemented
6400.167(b)On 11/23/16, Individual #1's physician ordered the morning dose of Seroquel to be discontinued. The medication was not discontinued until 11/25/16. On 10/12/16, Individual #1's physician ordered the morning dose of Klonopin to be discontinued and a decrease in Seroquel from 100mg twice daily to 50mg twice daily. Both orders were not completed until 11/9/16. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.VCS will ensure prescription medications and injections shall be administered according to the directions specified. The QA director retrained the program managers on 09/28/2017 on timeliness of administration and discontinuation of medications. Program managers and assigned staff will review the MAR on a continual basis to ensure compliance. Sign in sheet and outline are attached. (#36) Every medication administrator at the Stewart CLA have attended a medication administration refresher, which follows the Hear, See, Do format with a post-test to ensure competence. Training was completed on 10/02/2017. Sign in sheet, outline, and training packet are attached. (#37) All VCS medication administrators are required to attend this course during October 2017. To ensure no further infractions occur, the operations director and QA department will review a sample of MARs each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. 10/31/2017 Implemented
6400.168(e)Staff #1 and Staff #2 were trained as practicum observers. The summary sheet and trainer signature page were the only documents available for review. Staff #3, #4, and #5's annual medication practicum packet was not kept. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.VCS will ensure annual medication practicum packets are kept. The QA Associate, which oversees the medication administration documentation reviewed the regulation 6400.168(e), which explanation states that ¿copies of the annual practicum must be kept in the files.¿ Although the Annual Practicum form dated August 2013 from DPW, which includes the date and reviewers and observer¿s name is/has been kept in the medication administrators file, the surveyors stated the annual medication practicum is a packet, which must include secondary documentation of each of the reviews and observations. The QA Director trained the QA Associate on 9/07/2017 on the POC correction required. Sign in sheet is attached. (#34) As of 8/25/2017, this secondary documentation will be retained in each medication administrator and practicum observer file. A packet from a medication administrator, whose certification date was after 8/25/2017 is attached. (#35) 10/09/2017 Implemented
6400.181(e)(7)Individual #1's 3/11/17 assessment did not include his/her ability to move away from heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. VCS will ensure the assessment indicates the individual¿s ability to move away from heat sources. The QA Director retrained the program specialists on the inclusion of all information within the assessment, along with the need to send ISP corrections to the supports coordinator when adjustments need made. A team meeting for Individual #f 1 was held on 9/15/2017, at which time her ability to move away from heat sources was discussed and agreed upon. The sign in sheet and transcript from meeting are attached. (#27) The addendum to the assessment and the ISP correction form are also attached. (#33) The QA Director retrained the program specialists on 9/18/2017. Attached are the sign in sheet, and outline of the training.(#3) Program specialist reviewed their current assessments for accuracy with heat sources and have completed addendums, which are also attached. (#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(9)Individual #1's 3/11/17 assessment did not include documentation of disability. The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. VCS will ensure the assessment indicates the individual¿s disability. The QA Director retrained the program specialists on the inclusion of all information within the assessment, along with the need to send ISP corrections to the supports coordinator when adjustments need made. An addendum to the assessment is attached. (#27) The QA Director retrained the program specialists on 9/18/2017. Attached are the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for accuracy the individual¿s disability and have completed addendums, which are also attached.(#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached.(#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(13)(i)REPEATED VIOLATION - 7/19/16. Individual #1's 3/11/17 assessment did not include progress or regression over the past year in health.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. VCS will ensure the assessment indicates the individual¿s progress or regression over the past year in health. The QA Director retrained the program specialists on the inclusion of all pertinent information within the assessment, along with the need to send an addendum to the team when adjustments need made on 9/18/2017. An addendum to the assessment for Individual #1 is attached. (#33) Attached are also the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for inclusion of pertinent information with the individual¿s progression or regression over the past year in health and have completed addendums, which are also attached. (#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(13)(ii)REPEATED VIOLATION - 7/19/16. Individual #1's 3/11/17 assessment did not include progress or regression over the past year in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. VCS will ensure the assessment indicates the individual¿s progress or regression over the past year in motor and communication skills. The QA Director retrained the program specialists on the inclusion of all pertinent information within the assessment, along with the need to send an addendum to the team when adjustments need made on 9/18/2017. An addendum to the assessment for Individual #1 is attached.(#33) Attached are also the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for inclusion of pertinent information with the individual¿s progression or regression over the past year in motor and communication skills and have completed addendums, which are also attached.(#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis 10/09/2017 Implemented
6400.181(e)(13)(v)REPEATED VIOLATION - 7/19/16. Individual #1's 3/11/17 assessment did not include progress or regression over the past year 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. VCS will ensure the assessment indicates the individual¿s progress or regression over the past year in socialization. The QA Director retrained the program specialists on the inclusion of all pertinent information within the assessment, along with the need to send an addendum to the team when adjustments need made on 9/18/2017. An addendum to the assessment for Individual #1 is attached. (#33) Attached are also the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for inclusion of pertinent information with the individual¿s progression or regression over the past year in socialization and have completed addendums, which are also attached. (#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(13)(vi)REPEATED VIOLATION - 7/19/16. Individual #1's 3/11/17 assessment did not include progress or regression over the past year 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. VCS will ensure the assessment indicates the individual¿s progress or regression over the past year in recreation. The QA Director retrained the program specialists on the inclusion of all pertinent information within the assessment, along with the need to send an addendum to the team when adjustments need made on 9/18/2017. An addendum to the assessment for Individual #1 is attached. (#33) Attached are also the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for inclusion of pertinent information with the individual¿s progression or regression over the past year in socialization and have completed addendums, which are also attached.(#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached.(#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(13)(ix)REPEATED VIOLATION - 7/19/16. Individual #1's 3/11/17 assessment did not include progress or regression over the past year 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.VCS will ensure the assessment indicates the individual¿s progress or regression over the past year in community integration. The QA Director retrained the program specialists on the inclusion of all pertinent information within the assessment, along with the need to send an addendum to the team when adjustments need made on 9/18/2017. An addendum to the assessment for Individual #1 is attached. (#33) Attached are also the sign in sheet, and outline of the training.(#3) Program specialist reviewed their current assessments for inclusion of pertinent information with the individual¿s progression or regression over the past year in community integration and have completed addendums, which are also attached. (#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.181(e)(14)Individual #1's 3/11/17 assessment did not include his/her ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim. VCS will ensure the assessment indicates the individual¿s ability to swim. The QA Director retrained the program specialists on the inclusion of all information within the assessment, along with the need to send ISP corrections to the supports coordinator when adjustments need made. An addendum to the assessment and the ISP correction form are attached. (#33) The QA Director retrained the program specialists on 9/18/2017. Attached are the sign in sheet, and outline of the training. (#3) Program specialist reviewed their current assessments for accuracy with ability to swim and have completed addendums, which are also attached. (#6) Program Specialists completed their next assessment and submitted to the QA department, which are attached. (#7) To ensure no further infractions occur, the operations director and QA department will review a sample of assessments each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.183(7)(iii)REPEATED VIOLATION - 7/19/16. Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. VCS will ensure the ISP includes the individual¿s potential to advance in vocational programming. A team meeting was held on 9/15/2017, at which time her potential to advance in vocational programming was discussed and decided. The sign in sheet, and the transcript are attached. (#27) The ISP correction form is also attached. (#29) The QA Director retrained the program specialists on the inclusion of all information within the ISP and ISP corrections to the supports coordinator when adjustments need made on 9/18/2017. Attached are the sign in sheet, and outline of the training. (#3) Program specialist reviewed their individual¿s ISP for accuracy with potential to advance in vocational programming, and sent ISP Corrections as necessary, which are also attached. (#30) To ensure no further infractions occur, the operations director and QA department will review a sample of ISPs each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.183(7)(iv)REPEATED VIOLATION - 7/19/16. Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. VCS will ensure the ISP includes the individual¿s potential to advance in competitive community-integrated employment. A team meeting was held on 9/15/2017, at which time her potential to advance in competitive community-integrated employment was discussed and decided. The sign in sheet, and the transcript are attached. (#27) The ISP correction form is also attached. (#31) The QA Director retrained the program specialists on the inclusion of all information within the ISP and ISP corrections to the supports coordinator when adjustments need made on 9/18/2017. Attached are the sign in sheet, and outline of the training.(#3) Program specialist reviewed their individual¿s ISP for accuracy with potential to advance in competitive community-integrated employment, and sent ISP Corrections as necessary, which are also attached. (#32) To ensure no further infractions occur, the operations director and QA department will review a sample of ISPs each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.186(b)REPEATED VIOLATION - 7/19/16. Individual #1 did not date the 7/8/17, 4/21/17,1/25/17, or 10/11/16 Individual Support Plan (ISP) Reviews. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. VCS will ensure the program specialist and individual sign and date the ISP review upon review of the ISP. The QA Director retrained the program specialists on the format of the ISP review on 9/18/2017. Attached are the sign in sheet, outline, and example of the format, which includes a space for both the program specialist and individual to sign and date upon review of the document. (#1) Each program specialist completed their next ISP review, including the review signatures and dates, and submitted to the QA department, which are attached. (#2) To ensure no further infractions occur, the operations director and QA department will review a sample of ISP reviews each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.186(c)(1)Individual #1's 7/8/17, 4/21/17,1/25/17, and 10/11/16 Individual Support Plan (ISP) Reviews did not include his/her participation on the keeping active ISP outcome. The ISP outcome of coping skills was not reviewed. The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. VCS will ensure the ISP review includes monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home. The program specialist met with the team on 9/15/2017 to discuss the coping skills outcome for Individual #1, and VCS has been removed from the responsibility. The sign in sheet and transcript from the meeting are attached. (#27) Also, an ISP correction form is attached. (#28) The QA Director retrained the program specialists on the format of the ISP review on 9/18/2017. Attached are the sign in sheet, outline, and example of the format. (#1) Program specialists reviewed each outcome in the ISP to ensure data for the past 3 months were included. If an outcome was listed, which the residential program is not responsible, the program specialist met with supports coordinator to have that information changed in the ISP. Each program specialist completed their next ISP review, including the review and submitted to the QA department, which are attached. (#2) To ensure no further infractions occur, the operations director and QA department will review a sample of ISP reviews each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
6400.186(c)(2)REPEATED VIOLATION - 7/19/16. Individual #1's 7/8/17, 4/21/17,1/25/17, or 10/11/16 Individual Support Plan (ISP) Reviews did not include a review of the dental hygiene plan or refusal of treatment plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. VCS will ensure ISP reviews include a review of each section of the ISP specific to the residential home. The QA Director retrained the program specialists on the format of the ISP review on 9/18/2017. Attached are the sign in sheet, outline, and example of the format. (#1) Each program specialist completed their next ISP review and submitted to the QA department, which are attached. (#2) To ensure no further infractions occur, the operations director and QA department will review a sample of ISP reviews each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program specialists on an ongoing basis. 10/09/2017 Implemented
SIN-00070492 Renewal 02/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1's date of hire was 11/16/10. The only record of Staff #1 completing first aid/CPR training was not done until 12/27/13.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Valley Community Services will ensure program specialists and direct care professionals are trained within 6 months after the day of initial employment and annually thereafter on first aid/ CPR. Valley Community Services requires certification through American Red Cross; which is a 2 year recertification. Per regulation ¿the length of time on the certification will be acceptable and annual training is not required.¿ Staff #1¿s certification was submitted to surveyors during the exit interview. However, a copy of certification(s) is being resubmitted for re-approval. 06/26/2015 Implemented
6400.72(a)Individual #1 did not have screens in her bedroom window.Windows, including windows in doors, shall be securely screened when windows or doors are open. Valley Community Services will ensure windows, including windows in doors, are securely screened when window or doors are opened. Although the window with missing screen in individual #1¿s bedroom was not open, the screen has been positioned in the window. To ensure no further infractions occur, a house inspection will be completed by the managers monthly, starting August 2015. The form will include missing and/damaged screens. The manager will submit a maintenance request upon inspection and will submit the completed inspection form to the Operations Director. The Operations Directors will be required to complete a quarterly house inspection of each home and submit to Quality Assurance. 08/01/2015 Implemented
SIN-00043673 Renewal 02/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The porch, deck, ramp and hand rails were warn and the paint is extremely weathered and peeling. (a) Floors, walls, ceilings and other surfaces shall be in good repair. Partially Implimented/Adequate Progress CSS 6/7/13 VCS will ensure all surfaces are in good repair. The program managers will have retraining by the Quality Assurance Director on regulation 6400.67(a) by March 21, 2013. The porch, deck, ramp and hand rails will be painted with the correct outdoor product prior to 04/30/2013, as soon as the weather permits appropriate application. 04/30/2013 Implemented
6400.181(a)The assessment for Indivdual #1 did not contain information in the areas of : Communication, Personal Adjustment, Poisons, and Heat Sources. Partially Implemented/Adequate Progress CSS 6/7/13 (a) 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. VCS will ensure initial and annual assessment includes assessment of adaptive behavior and level of skills completed. VCS Summary of Assessment has been retooled to include all the required information. The program specialists retraining will be completed by the Program Services Director on regulation 181(a) by March 21, 2013. The sign in sheet, outline, and a completed revised Summary of Assessment will be sent on completion. To ensure further infractions do not incur, the Program Services Director will review Summary of Assessments for 3 months, ending 06/30/2013. 03/21/2013 Implemented
6400.181(c)The assessment for Indivdual #1 did not contain the basis of how the information was obtained. (c) The assessment shall be based on assessment instruments, interviews, progress notes and observations. Partially Implemented/Adequate Progress CSS 6/7/13 VCS will ensure initial and annual assessment includes the basis of how the information was obtained. VCS Summary of Assessment has been retooled to include the required information. The program specialists retraining will be completed by the Program Services Director on regulation 181(c) by March 21, 2013. The sign in sheet, outline, and a completed revised Summary of Assessment will be sent on completion. To ensure further infractions do not incur, the Program Services Director will review Summary of Assessments for 3 months, ending 06/30/2013. 03/21/2013 Implemented
6400.181(e)(14)The assessment for Indivdual #1 did not contain information in the areas of :The individual's knowledge of water safety and ability to swim. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim. Partially Implemented/Adequate Progress CSS 6/7/13 VCS will ensure initial and annual assessment includes the individual¿s knowledge of water safety and ability to swim. VCS Summary of Assessment has been retooled to indicate the level of knowledge and ability information. The program specialists retraining will be completed by the Program Services Director on regulation 181(14) by March 21, 2013. The sign in sheet, outline, and a completed revised Summary of Assessment will be sent on completion. To ensure further infractions do not incur, the Program Services Director will review Summary of Assessments for 3 months, ending 06/30/2013. 03/21/2013 Implemented
SIN-00198993 Renewal 01/24/2022 Compliant - Finalized