| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | There was not a current signed copy of rights in individual #1's record. | 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. | 1. What was done immediately to correct the specific issue cited?
The Director of Service Coordination had a discussion with the Program Specialist regarding the regulation (6400.31) (b) and that the rights form should be signed annually at the annual ISP meeting.
2. What specific change will be made?
The Program Specialist will review the rights forms with the participant immediately and then annually ¿ at the annual ISP meeting. The Program Specialist will ensure the participant and Program Specialist both sign and date the rights form annually at the ISP meeting. The rights form will be scanned to the ¿P¿ Drive (Horizon House shared drive) and placed in the Service Binder .
3. Who (by title) will make the change?
The Program Specialist is responsible to make the change.
4. When will the change be made?
The rights forms were updated on October 31, 2017.(Attachment 1)
5. What system has been implemented to make sure the same violation does not occur again?
a. The Program Specialists will assure that regulations and established procedures in reviewing, dating and properly signing the rights form are followed by having them signed annually at the ISP meeting. The Program Specialist will assure that signed copies are in the participant¿s service binder and saved to the ¿P¿ Drive (Horizon House shared drive).
b. Horizon House conducts quarterly qualitative reviews on a randomly selected basis. Results are quantified by Quality Improvement and distributed to management. The Director of Service Coordination will identify the need to update any documents during monthly supervision with the Program Specialists.
6. What education and training has been provided to staff?
The Director of Service Coordination reviewed regulation 6400.31 (b), and the established procedures at the monthly staff meeting on November 2, 2017. The Program Specialists are knowledgeable about the need to follow established procedures including having the rights form signed at the annual ISP meeting.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
The Director of Service Coordination will follow up with Program Specialist during monthly supervision and maintain documentation of due dates and completion of required documentation. In addition, Developmental Services management conducts quantitative (monthly) and qualitative record reviews (quarterly). Aggregated results are part of management¿s individual and division dashboard summaries of performance. Action Plans are created for any areas not meeting compliance. |
10/31/2017
| Implemented |
| 6400.76(a) | The sofa and loveseat in the living room had tears in the fabric, exposing the padding underneath. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. What was done immediately to correct the specific issue cited?
Sofa and loveseat was thrown away. Sofa from another room (second living room) was placed until new sofa and loveseat was ordered and delivered. (Attachment 1 - Purchase Requisition)
2. What specific change will be made?
Supervisors and managers routinely assess furniture to check for fraying materials. If the furniture is deemed beyond repair, the furniture will be discarded and new furniture will be purchased.
3. Who (by title) will make the change?
Supervisors and Managers.
4. When will the change be made?
Immediately and ongoing, thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
During monthly supervision, Program Director will review expectations with Home Coordinator in regards to properly monitoring the physical site.
6. What education and training has been provided to staff?
Staff counseled on the expectations of inspectors when they inspect residential homes. Emphasis of the training was placed on staff recognizing that all issues whether great or small should be properly addressed. Also, as issues arise staff was advised to forward concerns to management so that the proper steps can be taken. ex. purchasing new dresser, etc.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Home Coordinator will conduct ongoing monitoring the participants¿/site furniture and address any concerns on a continuous basis. Home Coordinator will file/forward copies of any maintenance/purchase requests when they are about to be or have been completed as a follow-up to the action plan. This type of record keeping will provide a snap shot of any gaps in the process of completing maintenance requests and if any support, training, etc is needed. |
10/20/2017
| Implemented |
| 6400.112(a) | There were no documented fire drills held during the months of July, August or September 2017. | An unannounced fire drill shall be held at least once a month. | 1. What was done immediately to correct the specific issue cited?
Fire drill was completed on October 19, 2017 and monthly thereafter. (Attachments 1,2,3 and 4)
2. What specific change will be made?
Supervisors and managers ensure fire drills are completed at each service location on a monthly basis. Supervisors and Managers have been directed to submit all fire drills to QI by the 5th of each month.
3. Who (by title) will make the change?
Supervisors, Managers and Program Directors.
4. When will the change be made?
Immediately, and ongoing, thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors and managers are responsible for ensuring drills are completed monthly. Program Directors review drills for compliance with all regulatory requirements at the time of monthly supervision.
6. What education and training has been provided to staff?
Supervisors and managers are educated on regulatory compliance during monthly supervisions and bi monthly supervisors meetings.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Fire Drill completions are documented on the Monthly paperwork Checklist form which is completed by the Supervisor or Manager and reviewed by the Program Director at the time of monthly paperwork review. Monthly paperwork is reviewed on or before the 26th of each month to ensure that there is time to complete drills that may have not been completed before the end of the month. |
10/19/2017
| Implemented |
| 6400.141(c)(15) | The annual physical examination dated 6/15/17 for individual #1 did not document diet or special feeding instructions. | The physical examination shall include: Special instructions for the individual's diet. | 1. What was done immediately to correct the specific issue cited?
The Primary Care Physician was contacted to schedule appointment to correct the physical. The physical was corrected to include information pertinent to diet instructions and special dietary needs (Attachment 1).
2. What specific change will be made?
Supervisors will pre-populate as much information on the annual physical as possible to ensure no area of the physical examination form is left blank. Supervisors or their designee will attend all annual physical appointments and review the form for completion prior to leaving the physician¿s office.
3. Who (by title) will make the change?
Supervisors and Managers will re-check the physical examination form prior to leaving the physician¿s office or instruct their designee to do so.
4. When will the change be made?
The change was instituted immediately and continues to be in practice.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors or their designee will attend all annual physical examination appointments. Prior to medical appointments, supervisors will pre-populate annual physical forms with the expectation that physician verify information by signing the annual physical form. Upon completion of the medical appointment, the clinic visit sheet will be scanned to the internal nursing team for review and to ensure compliance.
6. What education and training has been provided to staff?
Supervisors are instructed to complete medical support training upon hire and annually thereafter to ensure their knowledge and ability to properly complete medical appointments. Should nursing staff observe any blank areas on the physical at the time it is scanned to them, they will follow up with medical staff and supervisors to ensure errors or blanks are immediately addressed.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Nursing staff is to review all medical documentation before filing into each participant¿s electronic medical folder. Nursing staff is to review medical records during home visits and when completing quarterly qualitative record reviews. Nursing staff is to review annual physical at the time they complete annual medical history updates. Areas of non compliance, if any, will be addressed upon discovery. |
11/09/2017
| Implemented |
| 6400.142(a) | The date of individual #1's most recent dental examination was 7/19/16. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | 1. What was done immediately to correct the specific issue cited?
Dental appointment was competed on October 30, 2017 (Attachment 1).
2. What specific change will be made?
To ensure annual appointments are completed within specified timeframes, Supervisor¿s and managers have been advised to add the due date of 2018 medical appointments including dental to respective outlook calendars three months before due date of next appointment. Nursing staff will be copied on appointment dates at the time information is entered into the outlook calendar.
3. Who (by title) will make the change?
Supervisor¿s and Managers will populate due dates to outlook calendars.
4. When will the change be made?
Immediately and ongoing thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Program Directors will complete quarterly record reviews of participant health records. During the quarterly reviews and at the time the of site monitoring visits, supervisors will be directed to schedule any upcoming appointments and add those appointments to the outlook calendars.
6. What education and training has been provided to staff?
Supervisors to complete medical support training upon hire and annually thereafter to ensure their knowledge and ability to schedule and complete all medical appointments within specified timeframes.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Nursing staff to review all medical documentation before filing into each participants¿ electronic medical folder. Nursing staff to review medical records during home visits and when completing quarterly qualitative record reviews. Nursing staff to review due dates for annual appointments during site visits. |
10/30/2017
| Implemented |
| 6400.168(d) | The most recent annual Medication Administration practicum for staff #1 was completed 10/07/15 and this staff is currently administering 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?
RP was retrained in medication administration on 10/23/17; observations completed on 11/8/17.
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 front line, 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 Supervisory 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 then conduct med observations and MAR reviews. Management also monitors the observation due dates to review with med trainers prior to due dates. The Project Manager in QI provides a list of what was completed and who is still outstanding on a monthly basis. This listing and notification are 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 are 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 alerts 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 Supervisory Frontline Management, (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 reviewed with management and staff. |
11/08/2017
| Implemented |
| 6400.186(c)(1) | There were no monthly reviews of the ISP for individual #1 from January 2017 to the present. | 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 residential home licensed under this chapter. | 1. What was done immediately to correct the specific issue cited?
The task of completing monthly reports was assigned to a supervisor to complete. Monthly reports for Nov. 2017 to Jan. 2018 completed.
2. What specific change will be made?
House supervisors are responsible for completing monthly reports for each assigned location. In the absence of the house supervisor this task is now assigned to a temporary supervisor to complete monthly reports.
3. Who (by title) will make the change?
Program Directors will make the change of assigning a temporary supervisor to complete monthly reports in the absence of a house manager.
4. When will the change be made?
November 2017
5. What system has been implemented to make sure the same violation does not occur again?
Once the temporary supervisor is assigned to complete monthly reports in the absence of a house supervisor, the report is sent to the program specialist to review and sign. The completed report is reviewed and signed off with the participant. Once we have obtained the necessary signatures, it is filed in the participants¿ health care records.
6. What education and training has been provided to staff?
Newly hired supervisors will complete orientation training on how to complete monthly reports as well as an on-site orientation on the participants they are assigned. The supervisor will then complete monthly reports on a monthly basis. In the absence of a house supervisor, the program director assigns a temporary supervisor to complete monthly reports
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Once the temporary supervisor is assigned to complete monthly reports in the absence of a house supervisor, the report is sent to the program specialist to review and sign. The completed report is reviewed and signed off with the participant. Once we have obtained the necessary signatures, it is filed in the participants health care records. Quantitative record reviews are completed monthly by managers; the reviews are submitted to QI. QI distributes a monthly dashboard report to Program Director indicating the results of the submitted reviews. Program Directors reviews the report and makes needed adjustments if necessary. Qualitative reviews are completed quarterly by management staff which encompass the review of monthly reports. |
11/01/2017
| Implemented |
| 6400.217 | The consent for release of information for individual #1 was not signed. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| 1. What was done immediately to correct the specific issue cited?
The Director of Service Coordination had a discussion with the Program Specialist regarding the regulation (6400.217) and that the consent forms should be signed annually at the annual ISP meeting.
2. What specific change will be made?
The Program Specialist will review the consent forms with the participant immediately and then annually ¿ at the annual ISP meeting. The Program Specialist will ensure the participant and Program Specialist both sign and date the consent forms annually at the ISP meeting. The consent forms will be scanned to the (P) Drive (Horizon House shared drive) and placed in the Service Binder at the site.
3. Who (by title) will make the change?
The Program Specialist is responsible to make the change.
4. When will the change be made?
The consent forms were updated on October 31, 2017. (Attached)
5. What system has been implemented to make sure the same violation does not occur again?
a. The Program Specialists will assure that regulations and established procedures in reviewing, dating and properly signing the consent forms are followed by having them signed annually at the ISP meeting. The Program Specialist will assure that signed copies are in the participant¿s service binder and saved to the ¿P¿ Drive (Horizon House shared drive).
b. Horizon House conducts quarterly qualitative reviews on a randomly selected basis. Results are quantified by Quality Improvement and distributed to management. The Director of Service Coordination will identify the need to update any documents during monthly supervision with the Program Specialists
6. What education and training has been provided to staff?
The Director of Service Coordination reviewed regulation 6400.217 and the established procedures at the monthly staff meeting on November 6, 2017. The Program Specialists are knowledgeable about the need to follow established procedures including having the rights form signed at the annual ISP meeting.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring
activities and action plan follow-up.
The Director of Service Coordination will follow up with Program Specialist during monthly supervision and maintain documentation of due dates and completion of required documentation. In addition, Developmental Services management conducts quantitative (monthly) and qualitative record reviews (quarterly). Aggregated results are part of management¿s individual and division dashboard summaries of performance. Action Plans are created for any areas not meeting compliance. |
10/31/2017
| Implemented |