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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature in the bathtub measured 130.1*F, maintenance on site during inspection adjusted the temperature during the inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | What was done immediately to correct the specific issue cited?
Upon discovery on 11/15/2022 that the hot water temperature in the tub at this site location was 130.1 degrees, maintenance adjusted the water temperature during inspection. The matter was resolved on 11/15/2022.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. In order to ensure regulatory and agency expectations and compliance, all staff will be trained on the revised Weekly Residential Site Checklist and the identified process; the expectations in conducting a site inspection both formally (completing the required weekly inspection) and informally (simply recognizing regulatory areas when not completing the weekly requirement). The Site Supervisor is responsible for conducting the site inspection and completing the checklist. All staff are responsible for recognizing regulatory violations, or areas in need of improvement, and following the reporting process as identified in the process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation will initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and implementation of items and/or submission of a maintenance request. If the matter requires maintenance attention, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change. Maintenance will be responsible for assisting in the resolution should violations be discovered.
When will the change be made?
Changes went into effect on 11/16/22 when the water temperature was reduced. Additionally, the Weekly Residential Site Checklist has been implemented to ensure full site inspections take place on a weekly basis and violations are identified and resolved promptly.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors will submit checklists to their Program Director, who will ensure receipt and review of each. On a quarterly basis, Program Directors will complete Quarterly Residential Site Verification Visit. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022; hot water temperatures in bathtubs and showers may not exceed 120°F. Following the implementation of the revised Weekly Residential Site Checklist and its process, all Supervisors will be trained by Program Director on how to complete a site inspection thoroughly and accurately.
Attachment #19.2 |
11/16/2022
| Implemented |
| 6400.76(a) | The dresser belonging to Ind.#2 had missing knobs and need repaired. | Furniture and equipment shall be nonhazardous, clean and sturdy. | What was done immediately to correct the specific issue cited?
Program Director purchased and installed two (2) knobs to replace missing knobs on CB dresser on 11/15/22.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change went into effect on 11/15/2022. Additionally, the weekly residential site checklist and its process are implemented as of 1/13/2023.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022; furniture in individual bedrooms and family living areas shall be nonhazardous, clean, and sturdy which includes all furniture throughout the home to be assessed and in good repair. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #19.1 |
11/15/2022
| Implemented |
| 6400.141(c)(7) | A Mammogram for Individual #18 should be completed annually based on age, last exam was completed 9/18/2020. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | What was done immediately to correct the specific issue cited?
The site supervisor contacted the gyn doctor and scheduled the appointment. Mammogram completed on November 22,2022 and results obtained on November 29, 2022.
What specific change will be made?
The Supervisor will utilize the yearly medical calendar to keep track of appointments. During the time of the annual appointments the Supervisor will schedule for the upcoming year. If that is not possible the supervisor will mark the calendar at the 6-month period to schedule the yearly appointment. Upon completion of medical appointments, the Supervisor will scan medical documentation to the assigned agency nurse for review to ensure all information is completed on the physical form.
Who (by title) will make the change?
House Supervisor (Program Director in absence of Supervisor) and Agency Nurse
When will the change be made?
The change was made effective November 22, 2022.
What system has been implemented to make sure the same violation does not occur again?
When all medical appointments are completed, the Site Supervisor will scan the documents to the assigned agency nurse. The nurse reviews the medical documentation for accuracy and completion. Program Directors also review medical documentation on a quarterly basis.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on November 17, 2022. All were informed that each participant is to have a physical exam each year. All were made aware that failing to support an individual with completing medical appointments as scheduled, poses a health and safety risk and is a regulatory violation that requires the immediately follow up through resolution. Site Supervisors are aware that medical appointments are to be completed as prescribed and in accordance with regulations. All Site Supervisors have been trained on the medical calendar and utilizing the calendar to ensure regulatory compliance.¿
Attachment #19.4 |
11/22/2022
| Implemented |
| 6400.163(d) | The prescription medication for all individuals stored in the closet was not kept locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | What was done immediately to correct the specific issue cited?
On 11/15/2022 Program Director locked the closet where medications are kept. Keys replaced to their respective location, the home office.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting the site inspection and completing the checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation will initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change
When will the change be made?
Change went into effect on 11/15/2022.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/22/2022; prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #19 |
11/15/2022
| Implemented |
| 6400.181(f) | The program specialist did not provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting for Ind. #18. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | What was done immediately to correct the specific issue cited?
The program specialists have developed a tracking system and incorporates all aspects of the ISP process, which includes time frames for sending the ISP meeting invitation to the team members prior to the ISP meeting.
What specific change will be made?
The Director of Service Coordination will discuss various aspects of the ISP process in supervision with program specialists to ensure that they are following up in a timely manner with the ISP meeting notification to team members. This information will also be tracked on the ISP tracking system.
Who (by title) will make the change?
Program Specialist, Director of Service Coordination
When will the change be made?
The change was made 11/15/2022
What system has been implemented to make sure the same violation does not occur again?
The ISP Tracking system tracks the process 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 meeting date, including ensuring that the assessment will be sent out to the team members at least 30 days prior to the meeting.
What education and training has been provided to staff?
The expectations around following up to ensure that the assessment was distributed to team members at least 30 days before the ISP meeting was reviewed with the Program Specialist on 11/15/2022. Going forward, the automated ISP tracking and monitoring system will also be reviewed with new Program Specialists.
Attachment #19.5 |
11/15/2022
| Implemented |
| 6400.213(1)(i) | Individual #18 record did not contain identifying marks, it was omitted on the face sheet | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | What was done immediately to correct the specific issue cited?¿¿
Face sheet for participant SA, was corrected on 11/16/22, by documenting identifying marks. The corrected document was placed in SA's health record.¿
¿
What specific change will be made?¿
Program Specialist and Program Managers review face sheets during quarterly reviews, ensuring all areas are completed using the identified checklist.¿
¿
Who (by title) will make the change?¿
Program Specialist and Program Supervisor¿
¿
When will the change be made?¿
11/16/22¿
¿
What system has been implemented to make sure the same violation does not occur again?¿
Upon completion of the Face Sheet, Program Specialist or Program Supervisor will use the checklist that will ensure all areas of the participant¿s face sheet is filled in correctly. The chart review form has also been updated to ensure that it captures whether the Face Sheet has been completely filled out. Any incomplete areas on the Face Sheet will be immediately addressed by Program Specialist and Program Supervisor.¿
What education and training has been provided to staff?¿
Program Specialists were reminded of the need to ensure all personal information for participants is reviewed and updated on an annual basis, and that the form is completely filled out. The face sheet was reviewed with the program specialist outlining all the areas of the face sheet that must be completed.¿
Attachment #19.3 |
11/16/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no tape located within the site's First Aid Kit at the time of inspection. | 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?
On 11/17/2021, upon discovery tape was put into the first aid kit.
2. What specific change will be made?
A monthly Residential Site Checklist is currently being done for each site that includes the first aid kit. The required contents of the first aid kit have been added to the monthly Residential Site Checklist to ensure that this is reviewed and checked monthly by the Site Supervisor. A separate checklist of the items in the first aid kit will also be included on the inside of the lid or sleeve of the first aid kit in plain view so that each time the kit is used, staff are aware of the contents that should be present, and take actions to ensure that they are present if anything is missing.
3. Who (by title) will make the change?
The Site Supervisor and Program Director
4. When will the change be made?
12/17/2021
5. What system has been implemented to make sure the same violation does not occur again?
The Horizon House Residential Site Checklist form will be completed on a monthly basis to ensure the first aid kit is fully stocked with the required item. The Residential Site Checklist will be completed by the Site Supervisor who is responsible for replenishing the first aid kit. Items will be purchased and kept on hand when the items in the kit are about 75% depleted. The required contents of the first aid kit will also be affixed to the inside lid/or sleeve of the first aid kit with a reminder to staff to notify the Site Supervisor when the first aid kit supplies are low or missing.
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6. What education and training has been provided to staff?
The Program Director will educated staff on the requirements of an approved regulatory first aid kit for 6400 community homes by 12/17/21
Attachment #11 |
12/17/2021
| Implemented |
| 6400.82(f) | At the time of inspection, no soap could be located within the main bathroom or within Individual#1's personal bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | 1. What was done immediately to correct the specific issue cited?
At the time of discovery, soap was placed into the bathroom for use.
2. What specific change will be made?
Upon the beginning of each shift, staff on duty will ensure that soap is in the bathroom for the participants and all staff use. A staff on each shift will complete a Shift Checklist that includes checking that soap is in each bathroom. The availability of bathroom soap is also captured on the Monthly Residential Site Checklist that is done by the Site Supervisor. Access to the soap and back up supplies will always be available to staff at all times, who will ensure that it is placed in the bathrooms as needed.
3. Who (by title) will make the change?
The site supervisor will be responsible to ensure soap is always available and placed in the bathroom.
4. When will the change be made?
On November 17, 2021 soap was immediately placed in the bathroom of the home.
5. What system has been implemented to make sure the same violation does not occur again?
A Daily Shift Checklist has been developed for staff on each shift to check various areas of the site, and this includes soap in the bathroom. The Site Supervisor will review the Shift Checklists and sign off to ensure that all items in need of correction have been addressed. Unless the assessment and the individual support plan specify otherwise, soap will be placed in all bathrooms in the home.
6. What education and training has been provided to staff?
The staff was educated by the Program Director on the importance of having hand soap in the bathroom at all times for sanitary reasons on 12/17/21.
Attachment #11.1 |
12/17/2021
| Implemented |
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