| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | The outside step was loose and causes a hazard when stepped upon. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | 1. What was done immediately to correct the specific issue cited?
HH Real Estate Staff was notified of the safety hazard presented at the time of inspection, and the repairs were made on 11/26/21.
2. What specific change will be made?
A Daily Shift Checklist was created so staff can conduct a review of the site on each shift, and submit a work order for each area in disrepair to the Real Estate Dept. within Horizon House.
3. Who (by title) will make the change?
Horizon House Real Estate Operations Director, Site Manager, Program Director.
4. When will the change be made?
November 26, 2021.
5. What system has been implemented to make sure the same violation does not occur again?
Residential staff is responsible for completing the Daily Shift Checklist. The Site Supervisor will review the Shift Checklists and sign off to ensure that all items in need of correction have been addressed.
Managers are to submit a work order for any area found to be in disrepair immediately upon notice.
6. What education and training has been provided to staff?
Program Director met with site Manager following site inspection and reviewed process for submitting work orders for physical site areas in need of repair.
Attachment #3 |
11/26/2021
| Implemented |
| 6400.165(b) | (PRN)- Medication Robafen DM Cough Liquid, Acetaminophen 325mg and Anti-Diarrheal 1mg not found in individual#1's medication box at time of inspection. | A prescription order shall be kept current. | 1. What was done immediately to correct the specific issue cited?
Pharmacy was contacted to order all prescribed prn medications.
2. What specific change will be made?
Site Supervisor is responsible for completing a physical review of the medication administration record and supply of medications weekly to ensure all medications prescribed are available as needed. This will be documented on the Weekly Medication Administration Review Checklist
3. Who (by title) will make the change?
Site Supervisors and Program Directors
4. When will the change be made?
November 22, 2021.
5. What system has been implemented to make sure the same violation does not occur again?
A Weekly Medication Administration Review Checklist has been implemented to document the weekly medication review that is done by Site Supervisors. Site Supervisors are required to forward the Weekly Medication Administration Review Checklist to respective Program Directors weekly to ensure all prescribed medications are on site as required.
6. What education and training has been provided to staff?
Staff Meeting conducted during which time all Site Supervisors were directed by their respective Program Director to completed med reviews as required and forward verification of reviews before their last shift concludes weekly.
Attachment #3.1 |
11/22/2021
| Implemented |
| 6400.181(f) | The assessment for individual#1 was not provided to the team 30 days prior to the meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 1. What was done immediately to correct the specific issue cited?
An ISP Checklist was developed to capture all aspects of the ISP process, which includes time frames for submitting information to the Supports Coordinator and the rest of the individual¿s team members.
2. What specific change will be made?
ISP Checklist is documented beginning at the 120-day timeframe before the Annual Review Update of the ISP is due. It will capture the due dates of various items that are due prior to the ISP due date, including providing the assessment to individual¿s team members 30 days before the ISP meeting.
3. Who (by title) will make the change?
Program Specialist, Director of Service Coordination
4. When will the change be made?
The change was made 12/1/2021
5. What system has been implemented to make sure the same violation does not occur again?
The ISP checklist is completed by the Program Specialist beginning 120 days before annual review update (ARU) is due. The form includes contacting the Supports Coordinator and other team members to secure a date for the annual ISP. At 90 days before ISP is due, the assessment and consents are emailed to the Supports Coordinator.
6. What education and training has been provided to staff?
Program Specialist were trained on the use of the ISP checklist on 12/14/21. The ISP checklist was also added to the Program Specialist orientation curriculum for all new hires.
Attachment #3.2 |
12/01/2021
| Implemented |
| 6400.213(1)(i) | The photo provided for individual#1 was not dated and it is unable to be determined if this is a current photo. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 1. What was done immediately to correct the specific issue cited?
Face Sheet was updated to include current photo and date, and the health record was updated with the new form.
2. What specific change will be made?
The revised Face Sheet template indicating the date of the photograph has been distributed to the site for immediate use. The Face Sheet has been included as part of the annual consent packet, which is completed in succession with Participant Annual Assessment.
3. Who (by title) will make the change?
Program Specialists and Program Director
4. When will the change be made?
Change was made on 11/19/21
5. What system has been implemented to make sure the same violation does not occur again?
Face Sheets are being updated along with the consents and assessments on an annual basis. The Face Sheet Form has also been updated to include date photo was taken and signature of person completing form. Dated photograph will be added as an item under the Face Sheet section of the Chart Review Tool so that it can be reviewed by management staff on a quarterly basis.
6. What education and training has been provided to staff?
Program Specialists and Site Supervisors receive training on the completion and monitoring of Face Sheets during their initial on-site orientation. The new process was also addressed with them on 11/19/21 to ensure compliance.
Attachment #3.3 |
11/19/2021
| Implemented |