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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Fire drill dated 9/11/21, the amount of time it took for evacuation was missing. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 1. What was done immediately to correct the specific issue cited?
On 11/17/2021, the Regional Director met with Program Director to review the 6400.112c regulations that includes the elements of the fire drill forms, such as the evacuation time.
2. What specific change will be made?
The Regional Director reviewed the new Fire Drill Process and Annual Monthly Fire Drill Tracker with the Program Director. The Program Director will train the staff at the site by 12/31/21. The program director will conduct a thorough review of completed fire drills forms on a monthly basis to ensure that all drills are completed and the forms are completely filled out. Verification of this review will be captured on the Annual Monthly Fire Drill Tracker that will be reviewed monthly by the Regional Director during monthly supervisions with Program Directors.
3. Who (by title) will make the change?
The Site Supervisor, Program Director, Regional Director
4. When will the change be made?
12/31/2021
5. What system has been implemented to make sure the same violation does not occur again?
The Site Supervisor will submit the completed fire drill form to the Program Director by the 3rd week of the month. The program director will conduct thorough reviews of completed fire drills forms on a monthly basis and provide immediate education and feedback to the Site Supervisor when it is discovered that information is missing from the forms. Verification of this review by the program director will be documented on the Annual Monthly Fire Drill Tracker each month. During the program director¿s monthly supervisions with their site supervisor, an additional review of drills will be conducted during the meeting as an added precaution.
6. What education and training has been provided to staff?
The Regional Director reviewed regulation 6400.112c with the Program Director and stressed the importance of their oversite responsibility in their reviews of the fire drill forms to prevent the reoccurrence of the this citation.
Attachment #12.2 |
12/31/2021
| Implemented |
| 6400.46(b) | No record of annual fire safety training for Staff member#1 found in record at inspection. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | 1. What was done immediately to correct the specific issue cited?
The Program Director registered this staff for their annual fire safety training that will be conducted on 12/20/21.
2. What specific change will be made?
QI developed a training tracker in order to monitor and ensure that staff have completed their annual trainings on time. This tracker will be reviewed in the Quality Council meetings monthly.
3. Who (by title) will make the change?
Site Supervisor, Program Director, Regional Director, Chief Services Officer of DS, Learning and Development Manager
4. When will the change be made?
Staff will be trained on 12/20/21
5. What system has been implemented to make sure the same violation does not occur again?
The QI department created a training tracking system that has color coded indicators to notify the Program Director when staff trainings are almost due or overdue. The date on the Training Tracker Spreadsheet will automatically change to yellow if the trainings are due within the next 60 days, change dates to red for trainings that are past due, and show green for training dates that are current. This visual color coded system will easily alert Site Supervisors and Program Directors on what trainings are current, coming due, or past due. This tracker will be maintained by the Learning and Development Manager who will email it monthly and also present it in the Quality Council Meetings monthly.
6. What education and training has been provided to staff?
The program director reviewed the 6400.46b regulation with the site supervisor and stressed the importance that staff should complete their annual fire safety training that is conducted by a fire safety expert.
Attachment #12 |
12/20/2021
| Implemented |
| 6400.46(d) | No record of CPR/First Aid training found for staff member #1 at inspection. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | 1. What was done immediately to correct the specific issue cited?
The Program Director registered this staff for their CPR/First Aid training on 1/6/2022
2. What specific change will be made?
QI developed a training tracker in order to monitor and ensure that staff have completed their required trainings on time. This tracker will be reviewed in the Quality Council meetings monthly.
3. Who (by title) will make the change?
Site Supervisor, Program Director, Regional Director, Chief Services Officer of DS, Learning and Development Manager
4. When will the change be made?
1/6/2022
5. What system has been implemented to make sure the same violation does not occur again?
The QI department created a training tracking system that has color coded indicators to notify the Program Director when staff trainings are almost due or overdue. The date on the Training Tracker Spreadsheet will automatically change to yellow if the trainings are due within the next 60 days, change dates to red for trainings that are past due, and show green for training dates that are current. This visual color coded system will easily alert Site Supervisors and Program Directors on what trainings are current, coming due, or past due. This tracker will be maintained by the Learning and Development Manager who will email it monthly and also present it in the Quality Council Meetings monthly.
6. What education and training has been provided to staff?
The program director reviewed the 6400.46d regulation with the site supervisor and stressed the importance that staff should complete their first aid training 6 since months of hire and renew annually thereafter.
Attachment #12.1 |
01/06/2022
| Implemented |
| 6400.52(a)(1) | it could not be determined if Staff member #1 completed 24 hours of annual training as there was no training record found in the record upon review. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | 1. What was done immediately to correct the specific issue cited?
The Program Director registered the staff for the remaining hours needed to complete their annual 24 hour training requirements. These will be completed by 12/31/21.
2. What specific change will be made?
QI developed a training tracker in order to monitor and ensure that staff have completed their annual trainings and that the 24 hours of training have been completed on time. This tracker will be reviewed in the Quality Council meetings monthly.
3. Who (by title) will make the change?
Site Supervisor, Program Director, Regional Director, Chief Services Officer of DS, Learning and Development Manager
4. When will the change be made?
12/31/2021
5. What system has been implemented to make sure the same violation does not occur again?
The QI department created a training tracking system that has color coded indicators to notify the Program Director when staff trainings are almost due or overdue. The date on the Training Tracker Spreadsheet will automatically change to yellow if the trainings are due within the next 60 days, change dates to red for trainings that are past due, and show green for training dates that are current. This visual color coded system will easily alert Site Supervisors and Program Directors on what trainings are current, coming due, or past due. This tracker will be maintained by the Learning and Development Manager who will email it monthly and also present it in the Quality Council Meetings monthly.
6. What education and training has been provided to staff?
The program director reviewed the 6400.52(a)(1) regulation with the site supervisor and stressed the importance that staff should complete their annual 24 hours training related to their job skills and knowledge each year.
Attachment #12.3 |
12/31/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The First Aid kit did not contain a 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. | 1. What was done immediately to correct the specific issue cited?
The scissors were immediately placed in the first aid kit.
2. What specific change will be made?
Items for the first aid kit are included on the monthly residential checklist. This requires supervisor to check each month for required items, management will also review and verify items in the first aid kit during quarterly site visits and quarterly spot checks.
3. Who (by title) will make the change?
Supervisors will complete the monthly checklist on a monthly basis to ensure all items are in the first aid kit. Program Directors will review the monthly checklist during monthly supervision
4. When will the change be made?
The changes were made on 10/30/17 and ongoing checks instituted immediately.
5. What system has been implemented to make sure the same violation does not occur again?
The monthly checklist includes all the items that are required for the first aid kit.
These items will be reviewed and checked on a monthly basis. Program Directors will also check items at service locations during quarterly visits to site locations.
6. What education and training has been provided to staff?
Regulation 77 (b) was reviewed with all supervisors and staff. Staff were also instructed if any items are used from the first aid, items are to be returned to the first aid kit immediately.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Supervisors will use the monthly residential checklist to ensure all items are in the first aid kit. Program Directors will review the checklist during monthly supervision and verify during quarterly site visits. Any items that have been used will be replaced immediately. If items need to be replaced in the first aid kit, the supervisor will purchase needed items and place in the first aid kit. |
10/20/2017
| Implemented |
| 6400.81(k)(3) | There were no linens or pillow(s) on Individual #1's bed. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | 1. What was done immediately to correct the specific issue cited?
Sheets and a blanket were placed on Individual #1's bed.
2. What specific change will be made?
Staff and supervisor will ensure sheets and blankets are on Individual #1's bed when he will tolerate them. Individual #1's chooses not to use a pillow. The Supports Coordinator was advised about changes needed to the Assessment and ISP. (Attachment 1 -- Email)
3. Who (by title) will make the change?
Supervisor and Program Director will ensure staff keeps sheets and blankets on Individual #1's bed when he tolerates them. BK is also monitored to ensure he does not get tangled in the sheets and blankets to assure that using these items does not become a safety hazard.
4. When will the change be made?
The changes were made immediately and will continue to be monitored for compliance and safety concerns.
5. What system has been implemented to make sure the same violation does not occur again?
Information has been added to Individual #1's assessment (Attachment 2) of his choice to not use a pillow. Information has also been added that Individual #1 sometimes getting tangled in his sheets and blankets and will at times take them off of the bed. Staff does 30 minute bed checks to ensure the safety of Individual #1 when he is in bed.
6. What education and training has been provided to staff?
Staff was educated on the regulation to have sheets and pillows on Individual #1's bed. There are times when Individual #1 twists and turns in his sleep which causes him to get tangled in the sheets and blanket. He has done well recently, sleeping throughout the night with sheets and a blanket on his bed.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Since there are times when Individual #1's twisting and turning in his sleep can cause him to become tangled in the blankets and sheets, information has been included in his assessment. It also indicates that he may choose not to have a sheet or blanket on his bed and of his ch |
10/25/2017
| Implemented |
| 6400.168(d) | Staff person #1 last completed the Department's annual Medication Administration Practicum on 1/11/2016 and has continued to administer medication. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. What was done immediately to correct the specific issue cited?
JK was retrained in medication administration on 10/23/17; observations completed on 11/15/17.
2. What specific change will be made?
Staff is suspended from administering medications unless all components of the medication administration process are complete. Monitoring of upcoming observations dates and completion are provided by the QI unit to the residential management team. This includes Program and Regional Directors and the home supervisors and coordinators.
3. Who (by title) will make the change?
Management staff and Medication Trainers who have completed the medication administration train the trainers¿ course are responsible to adhere to the changes that have been made to the process.
4. When will the change be made?
The change began 10/21/17.
5. What system has been implemented to make sure the same violation does not occur again?
Horizon House Quality Improvement Unit manages a database identifying initial medication certification dates for all staff certified to give medications. Medication Trainers (Program Directors) and House Management staff are notified by QI when staff is due for bi-annual observations and bi-annual MAR reviews 30 days before recertification is due. Medication Trainers will then conduct med observations and MAR reviews. Management will also monitor the observation due dates to review with med trainers prior to due dates. The Project Manager in QI will provide a list of what was completed and who is still outstanding on a monthly basis. This listing and notification is provided to all levels of DS management and the appropriate medication trainer. In the event that there are individuals who do not meet the requirements for certification in medication administration, management will be responsible to stop the individual from administering medications immediately and the House Manager will assign staff who will administer medications. Staff medication administration assignments will be included on the shift schedules.
6. What education and training has been provided to staff?
Identified staff was retrained in medication administration and medication observations were completed.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
The QI developed data base is utilized to track all staff certified to administer medications. The initial date of certification is documented. QI will alert all levels of Management and medication trainers 30 days prior to the bi-annual observation and MAR reviews due dates for each certified staff person. Medication trainers then schedule to complete observations and MAR reviews. The completed documents are submitted to QI for input into the data base. Additional staff has completed the train the trainer¿s course for medication administration, thus increasing the number of available medication trainers. Bi-annual observations and MAR reviews are assigned to medication trainers to ensure they are completed before the due dates. The summary report is provided to regional Directors, Program Directors, Medication Trainers and House Management, House Managers, Coordinators or Supervisors) by QI detailing who completed the training and who may still be outstanding. In addition, the number of individuals due per given month and the number completed each month are documented on the monthly dashboard report distributed to Regional and Program Directors which is to be reviewed with management and staff. |
11/15/2017
| Implemented |
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