| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The front porch light was not operative. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| VCS will ensure that rooms, hallways, interior stairways, outside steps, outside doorway, porches, ramps and fire escapes are lighted to assure safety and to all floors, walls, ceilings and other surfaces are in good repair. The light was repaired on 08/29/2017 by the maintenance staff in the Carlisle area. The maintenance request is attached. (#25) All program managers were retrained on 9/14/2017 on this regulation by the QA Director. Sign in sheet and outline are attached. (#26) All maintenance requests and requisitions have been submitted and reviewed by the operations directors and facilities directors on October 3, 2017. These requests are attached. (#22) The operations directors will review each home to ensure compliance and report back to the QA department by October 20, 2017. To ensure no further infractions occur, the operations director and QA department will review a minimum of 4 CLA homes each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers an ongoing basis. |
10/20/2017
| Implemented |
| 6400.67(a) | A red paint stain, approximately 4 feet by 1 foot, stained the grey carpet in the laundry area. | Floors, walls, ceilings and other surfaces shall be in good repair. | VCS will ensure that all floors, walls, ceilings and other surfaces are in good repair. The facilities director contacted the home¿s owner to ensure replacement flooring was satisfactory. The Baums Company has been obtained to replace the carpeting in the laundry area and measured the area on 09/24/2017. Installation is scheduled for 10/09/2017. See attached work order (#23) All program managers were retrained on 9/14/2017 on this regulation by the QA Director. Sign in sheet and outline are attached. (#24) All maintenance requests and requisitions have been submitted and reviewed by the operations directors and facilities directors on October 3, 2017. These requests are attached. (#22) The operations directors will review each home to ensure compliance and report back to the QA department by October 20, 2017. To ensure no further infractions occur, the operations director and QA department will review a minimum of 4 CLA homes each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers an ongoing basis. |
10/10/2017
| Implemented |
| 6400.76(a) | There were 5 rusted chairs near the front porch ramp. The TV stand in Individual #2's bedroom was very unsteady. | Furniture and equipment shall be nonhazardous, clean and sturdy. | VCS will ensure that all furniture and equipment is nonhazardous, clean and sturdy. The chairs have been removed on 08/25/2017. Weather resistant furniture has been purchased. The receipt is attached. (#18) The TV stand in Individual #2¿s bedroom has been removed. The TV has been mounted to the wall in his room, see attached (#19). The program specialist has submitted an ISP Correction form stating that the individual chooses a minimalistic décor and will not permit added furniture or wall hangings in his bedroom. The individual will be asked at least annually if he would like to choose items for his room to ensure he continues to want minimal furnishings. The ISP Correction form is attached. (#20) All program managers were retrained on 9/14/2017 on this regulation by the QA Director. The sign in and outline is attached. (#21) All maintenance requests and requisitions have been submitted and reviewed by the operations directors and facilities directors on October 3, 2017. These requests are attached. (#22) The operations directors will review each home to ensure compliance and report back to the QA department by October 20, 2017. To ensure no further infractions occur, the operations director and QA department will review a minimum of 4 CLA homes each month starting October 1, 2017 forward. Reports will be compiled and reviewed with the program managers an ongoing basis. |
10/09/2017
| Implemented |
| 6400.110(a) | The smoke detectors in the basement and kitchen were not operative. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | VCS will ensure that all smoke detectors are operable. The company, Select Securities returned to the home and ensured all the smoke detectors were in working order and reviewed the system with the program manager on 10/03/2017. See the attached work order (#15). At the 9/14/2017 training, program managers were required to test each smoke detector at their home(s) and ensure that even if they have interconnecting system, each of the detectors can be used at their location for fire drills. See attached. (#16) The QA Director retrained the program managers on the inoperable fire alarm policy and procedure. The sign in sheet, outline, and policy are attached. (#17) The facilities director requested Select Securities to evaluate the system. To ensure no further infractions occur, the operations director will review fire drill records to ensure each smoke detector was checked. This will be completed on a monthly basis. |
10/09/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's 2/27/17 physical exam did not include information pertinent to diagnosis and treatment in case of an emergency. The section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | VCS will ensure physical exam include information pertinent to diagnosis and treatment in case of emergency, and that the exam contains no blank sections. The QA Director retrained the programs on the Annual Physical Exam form on 09/14/2017. The sign in sheet, outline, and formatted form are attached. (#13) Program managers who had annual physicals after 9/14/2017 submitted each to the QA department for review. Annual physicals are attached. (#14) To ensure no further infractions occur program managers are required to submit the Annual Physical Exam form to ensure compliance to the QA Department starting 9/15/2017 and ending 12/31/2017. Starting 01/01/2018, the operations director and QA department will review a sample of Annual Physical Exam forms each month moving forward. Reports will be compiled and reviewed with the program managers on an ongoing basis. Any blanks found on the forms must be corrected by returning to the individual¿s PCP for correction, which will be initialed and dated by the appropriate physician¿s office staff. |
10/09/2017
| Implemented |
| 6400.163(c) | Individual #1's 8/14/17, 6/26/17, 5/15/17, and 4/10/17 psychiatric medication reviews did not include the reason for prescribing the medication. Individual #1's medication reviews indicated he/she was taking 25mg of Lamictal however, Individual #1 was taking 150mg according to the medication logs. | 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 |
| 6400.181(e)(4) | REPEATED VIOLATION - 7/19/16. Individual #1's 6/20/17 assessment did not include supervision needs in the community. | The assessment must include the following information: The individual's need for supervision.
| VCS will ensure the assessment indicates supervision of needs. 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 9/12/2017, at which time his supervision was discussed and agreed upon. The sign in sheet and transcript from meeting are attached. (#4) The addendum to the assessment and the ISP correction form are also attached. (#5) 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 supervision 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)(viii) | REPEATED VIOLATION - 7/19/16. Individual #1's 6/20/17 assessment did not indicate if Individual #1 was able to manage money. Individual #1 was receiving $15 of pocket money. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | VCS will ensure the assessment indicates the individual¿s progress or regression regarding managing money. 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 9/12/2017, at which time his supervision was discussed and agreed upon. The sign in sheet and transcript from meeting are attached. (#4) The addendum to the assessment is attached. (#5) and the ISP correction form are also attached. (#10) 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 supervision 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(4) | Individual #1's Individual Support Plan (ISP) did not include supervision needs in the community. | 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. | VCS will ensure the ISP indicates supervision of needs and ensure the content is accurate in the ISP. 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 9/12/2017, at which time his supervision was discussed and agreed upon. The sign in sheet and transcript from meeting are attached. (#4) The addendum to the assessment and the ISP correction form are also attached. (#5) 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 supervision 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(5) | REPEATED VIOLATION - 7/19/16. Individual #1's 8/20/17 Individual Support Plan did not include the social, emotional, environmental needs plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | VCS will ensure the ISP, including annual updates and revisions include the protocol to address social, emotional and environmental needs of the individual, if medications have been prescribed to treat symptoms of a diagnosed psychiatric illness. Individual #1 SEE plan has been sent to the supports coordinator to be placed in his ISP and is attached. (#8) The QA Director retrained the program specialists on 09/18/2017. Attached are the sign in sheet, outline, and format for the ISP reviews. (#1) Program specialists have reviewed the ISPs to ensure the SEE plan is addressed and have sent the supports coordinators the plan requesting the need to place in the ISP. (#9) Program specialists are required to address the plan and any information utilized in their ISP reviews. Program specialists completed their next ISP review and submitted to the QA department, which are attached. (#2) Training also included the review of the annual assessment, which requires the SEE plan to be attached. The outline from this part of the training is also attached. To ensure no further infractions occur, the operations director and QA department will review a sample of the 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(b) | REPEATED VIOLATION - 7/19/16. Individual #1 did not sign or date the 7/27/17 Individual Support Plan (ISP) Review. | 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 4/30/17 and 7/27/17 Individual Support Plan (ISP) Reviews did not review the ISP outcome of community integration or independent living. | 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 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. Program specialists reviewed each outcome in the ISP to ensure data for the past 3 months were included. (#1) 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 4/30/17 and 7/27/17 Individual Support Plan (ISP) Reviews did not review the social, emotional, environmental needs 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 |
| 6400.213(11) | REPEATED VIOLATION - 7/19/16. Individual #1's 6/20/17 assessment indicated he/she is able to have alone time in the home within his bedroom and bathroom. He/she is able to be alone outside as long as staff can see him through the windows. Individual #1's Individual Support Plan indicated he/she can't be left home alone unsupervised. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | VCS will ensure the assessment indicates supervision of needs and ensure the content is accurate in the ISP. The QA Director retrained the program specialists on 09/18/2017 for the inclusion of all information within the assessment, along with the need to send ISP corrections to the supports coordinator when adjustments need made. Attached are the sign in sheet, and outline of the training. (#3) A team meeting for Individual #f 1 was held on 9/12/2017, at which time his supervision was discussed and agreed upon. The sign in sheet and transcript from meeting are attached. (#4) The addendum to the assessment and the ISP correction form are also attached. (#5) Program specialist reviewed their current assessments for accuracy with supervision 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 |