| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.70(d) | The first aid kit did not contain a thermometer. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | A monthly site inspection chart will be created and completed monthly so that any maintenance or general site concerns (such as appropriate items in first aid kits) may be addressed in a timely fashion. The appropriate regulations will be reviewed by all site staff. All materials will be presented no later than Friday, April 7, 2017.[The Program Director will conduct quarterly reviews of the First Aid Kit to ensure it is completed, starting immediately. SW 3.22.23] |
04/07/2017
| Implemented |
| 2380.89(h) | Staff indicated that they were not using the actual fire alarm during drills, but a YouTube video of an alarm sound. | A fire alarm shall be set off during each fire drill. | The site director will contact the landlord to discuss options for being able to set off the actual fire alarm when individuals are present while not setting the alarm off for the neighboring restaurant or business suites. The site director and program specialists will review appropriate regulations. Proof of progress will be presented no later than Friday, April 7, 2017.[The Program Director will contact the local fire department to conduct an evacuation of all participants to ensure that the fire alarms are operable within 10 days of receipt of this plan of correction. Documentation of the fire drill will be sent to the Department for review upon completion of the drill. In addition, the Program Director will send a letter to the complex landlord will be sent, within the next 5 days to advise them that an audible fire alarm must be set off during all fire alarms. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.91(a) | Individual #2¿s most recent fire safety training was completed on 10/25/16 and the previous fire safety training was completed on 2/10/15. | 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. | A quarterly book audit form will be developed, including current fire safety training, to ensure fire safety training is up-to-date and completed on time. The appropriate regulations will be reviewed by the site director and program specialists at least bi-annually to ensure that all participants' have completed the required fire safety training SW 3.23.17.. Materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |
| 2380.111(a) | Individual 1¿s most recent annual physical examination was completed on 4/17/15. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A policy has been written for the department that states for parents and guardians the necessity of on-time and complete physicals. Parents or guardians will be notified one month prior to the expiration of current physicals. The policy states that individuals who do not have a current physical will be suspended from the program until a current and complete physical is submitted. The appropriate regulations will be reviewed and signed off on by the program specialist and site director. Proof of up-to-date physical will be presented no later than Friday, April 7, 2017. [Individual #1 will completed a physical examination within 30 days of receipt of this plan of correction. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.113(a) | Staff #1¿s most recent annual physical examination was dated 9/30/14. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Proof of staff #1¿s updated physical will be presented no later than April 7, 2017. The human resources department has updated company policy to notify staff members individually of physical expiration date. Staff members who do not get their physicals in time are suspended until a physical is completed. The site director and program specialists will review all appropriate regulations. [The Program Director will create an auditing document to ensure that all staff have a physical every two years, within 15 days of receipt of this plan of correction and review the document at least quarterly and advise staff of the date that the bi-yearly examination is due. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.121(b) | Medications Ibuprofen, aspirin and Benzalkonium Chlroride were found unlocked in the first aid kit located in the first aid room. | Prescription and nonprescription medications shall be kept in an area or container that is locked. | All site staff will review the appropriate regulations. Daily cleaning charts will be created to include ensuring any and all medications are appropriately locked. All materials will be presented no later than Friday, April 7, 2017. [The Program Director will conduct monthly reviews of the medications in both the first aid room and first aid kit to ensure that all medications are locked at all times, starting immediately. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.121(e) | Several expired medication were found in a locked cabinet located in the first aid room including, Calamine lotion, Milk of Magnesia, Ear drops, Siltussin DM and Perineal clean up. The first aid kit contained expired medications including Ibuprofen, aspirin and Bezalkonium chloride. | Discontinued prescription medications shall be returned to the individual¿s family or residential program for proper disposal. | A monthly site inspection chart will be created and completed monthly so that any maintenance or general site concerns (such as expired medication) may be addressed in a timely fashion. The appropriate regulations will be reviewed by all site staff. All materials will be presented no later than Friday, April 7, 2017. [The Program Director will conduct monthly reviews of the medication cabinet and first aid kits to ensure that all expired medications are disposed appropriately, starting immediately. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.124(a) | Individual #2 is prescribed Perphenazine 8mg as a PRN medication but it was not on site or listed on the current medication administration record. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The site director will review and update the medication administration records to ensure accuracy monthly, and will do so regularly, thereafter. A monthly sign off sheet will be created to document review of the M.A.R. The site director and program specialists will review the appropriate regulations. All materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |
| 2380.181(a) | Individual #2¿s most recent annual assessment is dated 4/10/15. Individual #1¿s previous annual assessment was dated 5/8/15. | 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. | The program specialists will institute a ¿Client Calendar¿ to ensure dates for assessments, 90 day ISP reviews, and monthly paperwork is completed in a timely fashion. The program specialists and site director will be retrained on 90 day ISP reviews and will review the appropriate regulations. The site director will review and sign off on all annual assessments to ensure thoroughness. All materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |
| 2380.182(d)(5) | Individual #2¿s record did not contain a copy of the most recent ISP. | The plan lead shall develop, update and revise the ISP according to the following: Copies of the ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), shall be provided as required under § 2380.187 (relating to copies). | The program specialists will review appropriate regulations and going forward use a Quarterly Book Audit form when completing 90 day ISP reviews to ensure information in client records are up to date. All materials will be presented no later than Friday, April 7, 2017. [The Program Director will obtain a copy of Individual #2's current ISP and place in their record within the next 5 days of receipt of this plan of correction. The Program Director will review all participants records to ensure that a current ISP is maintained in their record, starting immediately. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.185(a) | Individual #1¿s ISP dated 9/18/16 outcomes including communication, reading and life skills. There was no documentation regarding these goals in the record. | The ISP shall be implemented by the ISP's start date. | The program specialists will be retrained on ISP outcomes and translating them into written goals, as well as review the appropriate regulations. Standardized goal sheets will be used to document progress on all goals. All materials will be presented no later than Friday, April 7, 2017. [The Program Director will ensure that Individual #1, monthly and quarterly ISP reviews document the outcomes related to reading, communication, and life skills within 5 days of receipt of this plan of correction. In addition, the Program Specialist will review all participants monthly and quarterly ISP reviews to ensure that the require documentation on outcomes is completed as required, starting immediately. SW 3.23.17] |
04/07/2017
| Implemented |
| 2380.186(a) | Individual #1¿s record did not include a 90 day ISP review for the period from 6/18/16 through 9/17/16. Individual #2¿s most recent 90 day ISP review was completed for the period from 2/216 through 5/1/16. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | The program specialists will institute a ¿Client Calendar¿ to ensure dates for assessments, 90 day ISP reviews, and monthly paperwork is completed in a timely fashion. The program specialists and site director will be retrained on 90 day ISP reviews and will review the appropriate regulations. The site director will review and sign off on all 90 day ISP reviews to ensure thoroughness. All materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |
| 2380.186(b) | Individual #2¿s 90 day ISP review for the period of 2/2/16 through 5/1/16 was not signed. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist will review the information on Individual #2¿s 90 day ISP review for the noted period with individual #2, and have them sign off. The site director will review and sign off on all 90 day ISP reviews to ensure thoroughness. All materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |
| 2380.186(c)(1) | Individual #2¿s record did not contain monthly ISP reviews for the period from August 2016 through November 2016. | 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 facility licensed under this chapter. | The program specialists will institute a ¿Client Calendar¿ to ensure dates for assessments, 90 day ISP reviews, and monthly paperwork is completed in a timely fashion. The program specialists and site director will be retrained on 90 day ISP reviews and will review the appropriate regulations. The site director will review and sign off on all 90 day ISP reviews to ensure thoroughness. All materials will be presented no later than Friday, April 7, 2017. |
04/07/2017
| Implemented |