| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.32(b)(4) | Staff person #2 was promoted to program specialist on 2/21/22. The agency did not request or review Staff person #2's degree or transcript qualifications until 7/26/22, when they were requested during the onsite inspection then subsequently issued and printed on 7/26/22. | The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Compliance with this chapter. | When it was discovered that Staff person #2's degree/transcript was missing from the personnel file, a transcript was obtained online, printed, and filed on 7/26/22. Although the transcript was not present, HR manager stated that it was reviewed prior to the promotion. |
08/17/2022
| Implemented |
| 2380.91(a) | Individual #1's current, 10/18/21 fire safety training did not include training on responsibilities during fire drills and evacuation procedures. According to documentation produced, Individual #1 only received training on the designated meeting place, exit routes and general fire safety training.
Individual #2's current, 4/22/22 fire safety training did not include training on responsibilities during fire drills and evacuation procedures. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | While the necessary information was covered during the trainings, it was not reflected on the training reports. Initial and Annual Fire Safety training reports were revised to include all necessary information including general fire safety, evacuation procedures/exit routes, responsibilities during fire drills, designated meeting place, and smoking procedures. (Attachments #1 and #2). |
08/17/2022
| Implemented |
| 2380.111(c)(1) | Individual #2's current, 3/31/22 physical examination record did not include an assessment of their medical history, current and past. The record stated, "cerebral palsy," but did not include their medical history or other current, medical diagnoses. According to their record, the individual is non-weight bearing, requires repositioning in their wheelchair every 2 hours, has a history of febrile seizures, gets blotchy all over their face when exited, requires a two person lift assist, needs briefs changed on a regular schedule daily as they do not utilize the toilet, uses an adaptive cup to drink, is at high risk for choking, requires supervision and proper positioning during meals, takes MiraLAX daily to prevent constipation, wears corrective bifocal lenses, and wears sunshades due to sensitivity to sunlight. | The physical examination shall include: A review of previous medical history. | A letter was faxed to Individual #2's physician requesting current and past medical history on 8/8/22. (Attachment #3) A completed medical history was returned on 8/8/22. (Attachment #4) |
08/08/2022
| Implemented |
| 2380.111(c)(4) | REPEAT from 9/1/21 annual inspection: Individual #1's current, 7/19/22 physical examination record does not include current vision and hearing screening results, or deferment from a physician. The fields were left blank. Additionally, their vision was marked as normal however, the attached lifetime medical history document states Individual #1 suffers from visual impairment and is diagnosed with strabismus, compound astigmatism and poor night vision.
Individual #2's current, 3/31/22 physical examination record did not include current vision and hearing screening results, or deferment from a physician. The fields were left blank. Additionally, their vision was marked as normal however, their record states Individual #2 wears corrective bifocal lenses, wears sunshades due to sensitivity to sunlight, and sees their optometrist yearly. The results of their most recent optometrist examination were not included with the physical examination record. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | A letter was faxed to Individual #1's physician on 8/8/22 requesting vision and hearing screening results. An updated physical was not received, so the letter was re-faxed on 8/17/22. (Attachment #6)
A letter was faxed to Individual #2's physician on 8/8/22, requesting current vision and hearing screening results. Updated physical, including results, was received on 8/8/22. (Attachment #7) |
08/17/2022
| Implemented |
| 2380.111(c)(7) | REPEAT from 9/1/21 annual inspection: Individual #1's current, 7/19/22 physical examination record does not include their health maintenance needs. The field was left blank.
Individual #2's current, 3/31/22 physical examination record did not include a review of their medications or medication regimen. The record stated "see list" but a list was not included or attached to the examination record. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | A letter was faxed to Individual #1's physician on 8/8/22 requesting health maintenance needs. An updated physical was not received, so the letter was re-faxed on 8/17/22. (Attachment #6)
A letter was faxed to Individual #2's physician requesting his medication regimen on 8/8/22. A list of medications was received the same day. (Attachment #4) |
08/17/2022
| Implemented |
| 2380.111(c)(9) | REPEAT from 9/1/21 annual inspection: Individual #2's current, 3/31/22 physical examination record did not include a complete list of their allergies. The physical examination record stated they were allergic to Bactrim and Morphine. Their emergency information form in their record stated Individual #2 was allergic to Bactrim, Pediazole, sulfa drugs, and Rondex. | The physical examination shall include: Allergies or contraindicated medication. | A letter was faxed to Individual #2's physician on 8/8/22 requesting a list of allergies. An updated physical/list of allergies was received the same day (Attachments #4 and #7). |
08/17/2022
| Implemented |
| 2380.111(c)(10) | REPEAT from 9/1/21 annual inspection: Individual #1's current, 7/19/22 physical examination record does not include information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A letter was faxed to Individual #1's physician on 8/8/22 requesting medical information pertinent to diagnosis and treatment in case of an emergency. No updated physical was received, so the letter was re-faxed on 8/17/22. |
08/17/2022
| Implemented |
| 2380.111(c)(11) | REPEAT from 9/1/21 annual inspection: Individual #1's current, 7/19/22 physical examination record does not include dietary recommendations. The field for this indicated dietary needs were, "n/a", or not applicable. However according to their current individual plan, Individual #1 is nearly edentulous, softer foods are best, they cannot chew the tougher cuts of meat, they will not eat anything hard, and their doctor recommends food to be cut into half inch pieces or smaller. | The physical examination shall include: Special instructions for an individual's diet. | Program specialist faxed a letter to Individual #1's physician on 8/8/22, requesting an updated physical with dietary recommendations completed. No updated physical was received, so the letter was re-faxed on 8/17/22. |
08/17/2022
| Implemented |
| 2380.173(1)(iv) | Individual #2's record did not include their religious affiliation. The field for this on their emergency information document in their record was left blank. The rest of their record did not include this information. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Program Specialist contacted Individual #2's father to get religious affiliation. Information was documented on Emergency Information form. (Attachment #8) |
08/04/2022
| Implemented |
| 2380.181(a) | Individual #1's 2/11/21 and 1/28/22 assessments are almost entirely verbatim to each other; therefore, not reflecting an assessment of the individual's current level of abilities and needs and any progress or regression of those skills over the previous 365 days. An example of the verbatim content: the lifetime medical history document attached to each assessment, "created" on 2/4/21 and 1/28/22 by agency staff, both state Individual #1 is a 44-year-old adult. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Program specialist who completed the 2021 and 2022 assessments is no longer employed by the agency. New program specialist was instructed to assess each individual yearly and update current abilities and needs to reflect any progress or decline. Future assessments will not be cut and pasted. |
08/17/2022
| Implemented |
| 2380.36(a) | Documentation produced for Staff person #2's current, 11/3/21 fire safety training did not include training in training on the facility-specific meeting place and evacuation procedures, responsibilities during fire evacuations/drills, the use of smoke detectors and fire alarms, and notification to the local fire department.
Documentation produced for Staff person #4's 10/18/21 fire safety training didn't include training in evacuation procedures, responsibilities, the meeting place, smoking safety, use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department. Staff person #4's 10/28/20 fire safety training didn't include training in the meeting place, the use of fire extinguishers, smoke detectors and fire alarms, and notification to the local fire department. These elements were missing from documented content discussed during the trainings.
Staff person #3's fire safety training record states "fire safety at avenues" as the content included in the training. The record does not indicate that all components of 2380.36(a) were included in the training. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | While training in the areas indicated took place, it was not reflected on the staff training reports. Reports were updated to encompass all required areas including general fire safety, evacuation procedures, responsibilities, designated meeting place, smoking safety procedures, use of fire extinguishers, smoke detectors and fire alarms, and notification of local fire department as soon as possible. (Attachment #9) |
08/17/2022
| Implemented |
| 2380.37(a) | The annual training kept for Staff person #1 did not include content, training source for some training topics listed, and copies of any certificates received.
The name of the fire safety video, creator of said video, and specific content within the video of Staff person #2's 3/30/21 and 11/2/21 fire safety training was not documented and kept. The documentation stated the training was a "fire safety movie" and "fire safety video."
Staff person #4's 10/18/21 fire safety training also didn't include the name of the instructor(s), content of training, or name of video watched if completed.
The content and training source for all of Staff person #2's 2022 and 2021 trainings was not provided. Examples include: the source for a lot of trainings listed as "self-read" but they were topics and titles of web-based trainings provided on the ODP website conducted/created by specific trainers. Staff person #2's 2022 trainings only listed the title of a training topic, or acronym of a training topic, but did not include the content of the training. An example was a documented, "ECP and HCP" trainings where the source listed was "self-read." Staff person #2's individual support plan (ISP) training that was self-read in 2021 and 2022 doesn't indicate if it was the most current ISP or the date of which ISP they read. Their 5/20/21 training in confidentiality and HIPAA stated a power point, handout, and activity was completed as part of the training but the content of those items wasn't produced.
The name of the trainer for Staff person #3's individual plan trainings was not kept. Their training record indicating individual-specific training came from an ISP but their record doesn't indicate who the trainer was that trained Staff person #3 on individual-specific information prior to working with the individuals. The training source for Staff person #3's trainings was not kept for: exposure control plan/hazard communication, quality management plan, dysphagia, railroad crossings, winter driving safety, standard precautions, and defensive driving for example. Their record only indicated the trainings were "video" or "self-read." | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Staff person #1's training records will be updated to include a comprehensive training record including date, title, source, and length of training, as well as individual training reports that also include content and certificates.
All content from trainings completed in program will be kept in a master file for review. |
08/17/2022
| Implemented |
| 2380.39(c)(6) | An in-person training component was not provided to the individual-specific trainings for Staff person #2 and #3 in 2022 and 2021. According to their training record, trainings on individual specific plans and protocols, that included behavior support plans, were self-read documents and a trainer did not conduct the trainings. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Program staff training reports were updated to include program specialist/supervisor as the instructor for ISP, SEEN plans, seizure protocols, etc. Behavior specialists will do individual trainings for anyone with a behavior plan. (Attachment #10) |
08/17/2022
| Implemented |
| 2380.126(a)(13) | The name of the staff person who administered medications to Individual #3 at 2pm on 1/21/22, 3/18/22, and 4/29/22 was not recorded on the individual's medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff person in question will receive re-training on Lesson 8 of the medication administration training, "Documentation," which references the signature list/central record. |
09/01/2022
| Implemented |
| 2380.129(a) | Staff person #4 was certified via the agency's medication administration trainer to administer medications to individuals on 3/12/21 and not again until 3/15/22, outside the annual time frame.
Staff person #2 was due for recertification of their annual medication administration training in 1/10/21. The facility was closed until 2/8/21 and Staff person #2 did not return to work until 7/6/21. Upon reopening and returning to program, Staff person #2 did not complete two additional medication administration observations and one practice activity for each type of documentation within 60 days of the annual practicum anniversary date. Staff person #2 didn't complete the 3 required observations until 7/9/21, their record does not indicate when the practice activity mar was completed, and their record does not include a practice activity observation. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Staff person #4's original certification date was 3/14/2018, therefore her annual practicum was due by 3/14/2022, not 3/12/22 as stated above. Staff person #4 called off on 3/14/22, therefore her practicum was completed when she returned on 3/15/22. |
08/17/2022
| Implemented |