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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed 4-16-16. The Certificate of Compliance has an expiration date of 6-9-16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Armstrong Care, Inc. will in-service all Program Specialists and all Supervisors on making sure a self-assessment of each home serving eight or fewer individuals is completed within 3 to 6 months prior to the expiration date of the Armstrong Care, Inc.`s certificate of compliance. This in-service was completed by July 29, 2016. Also, Armstrong Care, Inc. will remind all Program Specialists and Supervisors to begin completing the self-assessment from February 1st of each year and to be completed and turned in no later than February 28, of each year. This process will be monitored by the Program Specialist Manager and the Program Director in order to prevent similar deficiencies from reoccurring in the future. [Documentation of reviews shall be kept. (AS 9/20/16)]
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08/08/2016
| Implemented |
| 6400.141(c)(14) | The physical examination dated 7/29/15 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 physician was contacted by Armstrong Care, Inc. supervisor to clarify if there was any medical information pertinent to diagnosis and treatment in case of an emergency that needed added to the physical exam for Individual #1. Individual #1¿s physical was completely filled out by his/her PCP and return to his/her Supervisor and it will be forwarded to licensing. Additional safeguards will be implemented to ensure this section, and no other sections of the annual physical form are blank going forward. A Physical Examination Training was held on Monday July 25, 2016 with all Residential Supervisors, and Program Specialist. Emphasis was brought to their attention to not have any section on the physical left blank when leaving the physician¿s office. Medical Information Pertinent to the Diagnosis and Treatment in Case of Emergency along with all other areas of the physical will be completed by the physician before leaving the office the day of the individual¿s appointment. There are Sections that are appropriate for staff to complete prior to the appointment. These sections are demographics, history, medication and allergy type information that the doctor generally asks the patient during the exam. They are also already current on the Emergency Medical Information form that is being shared with the physician at the appointment. These items, the EMI and the sections of the physical completed by staff should ALWAYS match going into the exam. The physician can make changes in these sections as he determines is necessary. Residential Program Supervisors received training on July 25, 2016 for implementation of this form. Training verification will be sent to licensing. [Individual #1's physical examination was updated on 8/3/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. Within 30 days or receipt of the plan of correction and prior to entering in to the individuals' records, the residential supervisor(s) and program specialist(s) shall review the individuals' current physical examination documentation to ensure the physical examination is completed, sign and dated by the physician, certified nurse practitioner or licensed physician's assistant and there are no require areas left blank and missing information shall be obtained. At least quarterly, the program director shall review a 25% sample of physical examination to ensure the physician, certified nurse practitioner or licensed physician's assistant completed, signed and dated as required. (AS 8/18/16)] |
08/08/2016
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.105 | Two cardboard boxes were stored in an area approximately three feet wide between the hot water tank and the wall in the basement of the home. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The flammable items were removed from the furnace area on July 2, 2015. An addition to an existing House Inspection Checklist has been made, for the Residential Supervisor to complete weekly, beginning August 1, 2015. ( An email of the weekly checklist will be emailed, with the addition/change highlighted.) The checklist will be verified by the Director of Safety prior to the end of the month and forwarded to the Program Director for approval. Emergency or safety issues will be resolved between the Residential Supervisor and Program Director immediately. Completed checklists will be utilized in conducting Self Inspections. |
08/01/2015
| Implemented |
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