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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, date of admission 7/31/17, had a statement acknowledging receipt of the information on rights completed 1/11/18. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Review of individuals files will occur at two times. First when admitting new individuals into the group home and secondly for individuals already living in the group homes.For new individuals the review will be done when completing the new admissions form. The admissions form will be completed by the Clinical Director. The form will be signed by the Clinical Director and filed in the individual client file once all requirements have been met.
For individuals currently living in the group homes the check will be completed on a monthly basis, as part of the monthly client file audits. The Program Coordinators and Clinical Director will insure that files are complete and accurate. Noncompliance will be identified, the Clinical Director will meet will the House Manager and Program Specialist to correct any issues and retrain.
The effective date of this change is June 1, 2018.
Responsible Party: Program Director, Clinical Director/RN
[Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure all individuals are informed of the individual rights and statement are signed and dated acknowledging receipt of the information of rights, timely. Documentation of the training shall be kept. (AS 6/21/18) |
06/01/2018
| Implemented |
| 6400.68(b) | On March 9, 2018 at 11:15 AM, the hot water temperature measured at 127.5 degrees Fahrenheit at the bathtub, in the bathroom by the bedrooms. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | House Managers were reinstructed on the 6400.68 regulation and have began to test water temperatures on a weekly basis. Water Temperatures will be reflected on the house weekly visit/inspection sheet. Effective July 1, 2018 the house direct care staff will check water temperatures on a daily basis. A water temperature log will be kept at each house. The house manager will review the log weekly.
Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur.
Effective Date: June 1, 2018
Responsible Party: House Managers, Program Director and Compliance Officer
[Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure hot water temperatures in bathtubs and showers do not exceed 120°F. Documentation of the training shall be kept. (AS 6/21/18)] |
06/01/2018
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. House Managers have reviewed the 6400.77 regulations on contents of the First aid kit. The agency has developed a content card to be added as part of the weekly house visit/inspection. House managers will verify the contents of the First aid kit on a weekly basis. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur.
Effective Date: June 1, 2018
Responsible Party: House Managers, Program Director and Compliance Officer
[The house manager replaced the scissors on March 12, 2018. Within 30 days of receipt of the plan of correction, all staff persons shall be educated on the required items in first aid kits and the aforementioned list, and the location of replacement and replenishment supplies and procedures to ensure all first aid kits contain all required items at all times and required items are replenished and replaced as needed. (AS 6/21/18)] |
06/01/2018
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination completed 2/27/18 did not include immunizations. This section was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The Agency hired a Clinical Supervisor/LPN as the training coordinator on March 5, 2018. This position will insure that all required Office of Developmental Program annual trainings are completed.
The Clinical Supervisor/LPN will insure that all staff meet the Physicals and required medical tests are completed.
Effective Date: June 1, 2018
Responsible Party: Clinical Supervisor/Training Coordinator, Clinical Director
[NOT ACCCPABLE, PLAN OF CORRECTION DOES NOT ADDRESS THE VIOLATION. Immediately, the CEO or designee shall obtain Individual #1's immunizations. Immediately and upon completions, the CEO or designee (trained in the requirements of individual physical examination as per 6400.141(c)(1)-(15), Documentation of trainings shall be kept) shall audit all individuals' most recent physical examination to ensure all required information is included. Missing information shall be immediately obtained. Documentation of audits shall be kept. (AS 6/21/18)] |
06/01/2018
| Implemented |
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