| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The operator for the right side of the window in the hall bathroom has broken away from the wall requires repair. The window has separate operators on each side that operate independently of each other. The left side of the window opens but the right side requires the repair for full function. | Floors, walls, ceilings and other surfaces shall be in good repair. | Attachment 1.5
1. What was done immediately to correct the specific issue cited?
On 11/14/23, the assigned maintenance technician repaired the operator handle on the window.
2. What specific change will be made?
The Site Supervisor is responsible for meeting weekly with the Program Director to review weekly residential site checklist and any outstanding maintenance items.
3. Who (by title) will make the change?
Program Director
4. When will the change be made?
11/16/23
5. What system has been implemented to make sure the same violation does not occur again?
The site manager is responsible for submitting a weekly site checklist every Thursday and reviewing this checklist with the Program Director upon submission. The review consists of identifying areas resolved, in need of repair, outstanding, and new requests not yet submitted.
6. What education and training has been provided to staff?
Program Director reviewed and reiterated the purpose and completion of the weekly site checklist with Site Supervisor. Additionally, the Program Director and Site Supervisor reviewed the maintenance request process and being proactive if items remain outstanding. |
11/16/2023
| Implemented |
| 6400.72(a) | There are two windows on each end of the main window grouping in the living room that can open but do not have screens in them. Screens need to be obtained for and placed in the two windows. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Attachment 1.4
1. What was done immediately to correct the specific issue cited?
On 11/13/2023, Program Director and Site Supervisor submitted a maintenance request for screens to be replaced in the windows.
2. What specific change will be made?
The Site Supervisor is responsible for meeting weekly with the Program Director to review weekly residential site checklist and any outstanding maintenance items.
3. Who (by title) will make the change?
Program Director
4. When will the change be made?
11/16/23
5. What system has been implemented to make sure the same violation does not occur again?
The site manager is responsible for submitting a weekly site checklist every Thursday and reviewing this checklist with the Program Director upon submission. The review consists of identifying areas resolved, in need of repair, outstanding, and new requests not yet submitted.
6. What education and training has been provided to staff?
Program Director reviewed and reiterated the purpose and completion of the weekly site checklist with Site Supervisor. Additionally, the Program Director and Site Supervisor reviewed the maintenance request process and being proactive if items remain outstanding. |
11/16/2023
| Implemented |
| 6400.181(a) | 515 days elapsed between the 6/17/22 annual assessment and the 11/13/23 annual assessment for individual 4. This exceeds the annual (365 day) requirement. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Attachment 1
1. What was done immediately to correct the specific issue cited?
Because of staffing shortages in the position of Program Specialist, effective November 2023, existing Horizon House management personnel were assigned to function in the capacity of Program Specialist to complete the responsibility of individual assessments while recruitment for new employee occurs.
Reference review of Program Specialist job description dated 11/6/23.
2. What specific change will be made?
In November 2023, identified management personnel meeting the qualification of Program Specialist was assigned to complete annual assessments.
3. Who (by title) will make the change?
The Chief Service Officer made the change to address staffing shortage in the position of Program Specialist.
4. When will the change be made?
The change was made effective November 2023.
5. What system has been implemented to make sure the same violation does not occur again? Effective November 2023, when a position of Program Specialist is vacant and extends beyond 30 days, management personnel who met the requirements of Program Specialist and have completed orientation on the provisions of the assessments, shall be assigned on an interim basis to perform timely completion of assessments.
6. What education and training has been provided to staff?
As part of orientation, the assigned Program Specialist reviewed all sections of the assessment on November 6, 2023. |
11/14/2023
| Implemented |
| 6400.181(e)(14) | The assessment for individual 4 does not indicate whether he has the ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Attachment 1.2
1. What was done immediately to correct the specific issue cited?
On 11/14/2023, Program Director and Program Specialist retrieved and reviewed the current assessment for this participant. The Program Director identified the citation area and was educated on the addendum process to update assessment. The assessment was updated to reflect the status of the participants' ability to swim; this information now matches the ISP.
2. What specific change will be made?
Program Directors were assigned Program Specialist caseloads in the interim until additional Program Specialists are hired. During this time, Program Directors are trained and assigned to specific site locations to ensure updated and current assessments are completed and distributed accurately and within their timeframes, as well as match the information included within the ISP. Should discrepancies be discovered, the person discovered is responsible for notifying the team and ensuring consistency.
3. Who (by title) will make the change?
Director of Service Coordination.
4. When will the change be made?
12/1/2023
5. What system has been implemented to make sure the same violation does not occur again?
The program Director identified for this temporary position was provided with a current assessment form and the expectations of completing the form correctly and entirely, as well as comparing the assessment to the information within the ISP.
6. What education and training has been provided to staff?
The Program Director temporarily assigned was educated on the assessment addendum process and the importance of consistency throughout the assessment and ISP. |
12/01/2023
| Implemented |
| 6400.32(r) | The statement of individual rights for individual #4 signed on 7/24/23 does not include a statement regarding the right to lock the individual's bedroom door for individual 4. | An individual has the right to lock the individual's bedroom door. | Attachment 1.3
1. What was done immediately to correct the specific issue cited?
Following receipt of this citation, the Quality Improvement Director revised both the Participant Rights policy and the corresponding Participant Rights Form. The revision made align with the 6100, 6400, 6500, and 5310 regulations pertaining to individual rights. Upon review of the updates and revisions necessary, the official policy was made effective on 3/18/24 with the signature of the CEO.
2. What specific change will be made?
Participant Rights policy was updated to reflect the 6100, 6400, 6500, and 5310 regulations pertaining to individual rights. Employees and participants are responsible to adhere to these expectations. Additionally, the participant rights form is a document that each participant receives and is educated on annually.
3. Who (by title) will make the change?
Quality Improvement Director
4. When will the change be made?
Change was made beginning 11/2023 and finalized on 3/18/2024.
5. What system has been implemented to make sure the same violation does not occur again?
The revised policy reflects the regulations exactly. All rights are to be adhered to by both participants and staff.
6. What education and training has been provided to staff?
Education and training on the revised policy is the supervisor's responsibility. Program Directors and Site Supervisors are responsible for reviewing these revisions with their site staff and participants. Specifically staff have been educated on the right of participant's to lock their bedroom door unless otherwise specified throughout the ISP. |
11/14/2023
| Implemented |
| 6400.163(h) | There was a box containing Bengay Ultra Strength Cream, prescribed to be applied to affected area two times a day as needed (PRN) for pain in back or affected areas as needed for pain, that expired 11/01/23 in the medication box for individual #4. There was another box containing the same medication that was not expired, but the expired medication had not been removed from the medication box and destroyed in a safe manner according to applicable Federal and State statutes and regulations for individual 4. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Attachment 1.6
1. What was done immediately to correct the specific issue cited?
Immediately, the site supervisor removed the Bengay from the participant¿s medication bin on 11/13/23. A medication disposal log was completed, and the medication was disposed of on 11/13/23. A replacement Bengay (PRN) was obtained and placed in the bin for use. On 11/20/23, the Program Director met with Site Supervisor to review medication administration checklist, which requires a medication check at least three (3) times per week. These weekly checks include the assessment of any expired medication within the medication bin and the process to resolve.
2. What specific change will be made?
The medication review checklist reflects the expectation of completing medication checks at least three (3) times per week. Program Director is responsible for meeting with the Site Supervisor monthly to discuss and review the completed medication administration checklists. Program Director and Site Supervisor are responsible to discuss and review any expired medications discovered and/or addressed.
3. Who (by title) will make the change?
Program Director and Site Supervisor
4. When will the change be made?
11/20/2023
5. What system has been implemented to make sure the same violation does not occur again?
The medication administration checklist is completed by the Site Supervisor at least three (3) times per week. When completed weekly, discrepancies and areas of concern are immediately discovered and resolved.
6. What education and training has been provided to staff?
The Program Director reviews the medication administration checklist with the Site Supervisor monthly. Program Director provides retraining if during supervision it is discovered that the Site Supervisor would benefit from additional assistance. The Site Supervisor is responsible for the resolution of identified medication discrepancies upon discovery. |
11/20/2023
| Implemented |
| 6400.181(f) | The program specialist did not send individual # 4's annual assessment out to the team 30 days prior to the individual service plan (ISP) meeting. The individual's ISP meeting was held on 7/24/23 and the annual assessment is documented as distributed to the team on 11/13/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Attachment 1.1
1. What was done immediately to correct the specific issue cited?
Because of staffing shortage in the position of Program Specialist, effective November 2023, existing Horizon House management personnel were assigned to function in the capacity of Program Specialist. The responsibility is inclusive of the responsibility to complete individual assessments and distribute to team members within 30 days of ARU date while recruitment for new employee occurs.
Reference review of Program Specialist job description dated 11/6/23.
2. What specific change will be made?
On 11/23 identified management personnel meeting the qualification of Program Specialist was assigned to complete annual assessments.
3. Who (by title) will make the change?
The Chief Service Officer made the change to address staffing shortage in the position of Program Specialist.
4. When will the change be made?
The change was made effective November 2023.
5. What system has been implemented to make sure the same violation does not occur again? Effective November 2023, when a position of Program Specialist is vacant and extends beyond 30 days, management personnel who meet the requirements of Program Specialist and have completed orientation specific to service coordination duties and responsibilities. Theses duties include completion and distribution of the assessments within 30 days of ARU date.
6. What education and training has been provided to staff?
As part of orientation, the assigned Program Specialist reviewed all sections of the assessment inclusive of required distribution dates on November 6, 2023. |
11/14/2023
| Implemented |