Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.44(b)(18) | Individual #1 had a seizure protocol which indicated that if his/her seizures last more than 4 minutes, staff were to call 911 and take him/her to the hospital. The program specialist indicated on 10/3/16 that all staff working in the home were not trained on this protocol. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Protocol was written and attached to seizure chart for his daily book and personal vita information.All staff working with individuals with a diagnosis of a seizure disorder will have completed seizure management and protocol training as given by HCQU and follow along with their instructions for individuals, unless otherwise specified by their physicians. House supervisors and Program Director will insure this is completed.
01/06/2017
|
10/08/2016
| Implemented |
6400.46(a) | Staff #1's date of hire was 2/22/16. He/She was not trained in his/her job responsibilities yet at the time of licensing on 10/3/16. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Staff reviewed and signed job duties. copy attached.The Normalization and History of Developmental Disabilities Training material shall be presented to all new hires by the The job description shall be reviewed in detail at the preservice training and signed by the employee. Upon completion of the preservice training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file.
The Executive Director has trained the accounting manager in the specific documents required for all employees. The accounting manager will review the personnel file to insure that all required documents are in place and notify the Executive Director of any additional information needed. The Executive Director shall contact any employee who does not have all of the required documentation on file in order to obtain such documentation.
Executive Director during the first part of preservice training and all new hires will return the material to the Program Director or House Coordinatorwith their signature indicating that they have read the material at the time of the second part of preservice traininig.
The Program Director previously responsible for this is no longer employed by the provider. The current Program Director has been trained in this requirement and will be monitored by the Executive Director.
|
10/09/2016
| Implemented |
6400.46(e) | Staff #1's date of hire was 2/22/16. At the time of licensing on 10/3/16, he/she did not have training on the principles of normalization or rights. He/she did not have training on the areas of mental retardation until 3/31/16, more than 30 days after employment. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Staff reviewed and completed. Copy attached. Moving forward, a new staff was hired on 12/08/2016 and completed training on 12/10/2016 The Normalization and History of Developmental Disabilities Training material shall be presented to all new hires by the The job description shall be reviewed in detail at the preservice training and signed by the employee. Upon completion of the preservice training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file.
The Executive Director has trained the accounting manager in the specific documents required for all employees. The accounting manager will review the personnel file to insure that all required documents are in place and notify the Executive Director of any additional information needed. The Executive Director shall contact any employee who does not have all of the required documentation on file in order to obtain such documentation.
Executive Director during the first part of preservice training and all new hires will return the material to the Program Director or House Coordinatorwith their signature indicating that they have read the material at the time of the second part of preservice traininig.
The Program Director previously responsible for this is no longer employed by the provider. The current Program Director has been trained in this requirement and will be monitored by the Executive Director.
|
12/10/2016
| Implemented |
6400.62(a) | Individual #1 was assessed by the agency to be unsafe around poisonous materials. A number of poisonous materials that contained a label indicating "contact poison control center if ingested" or "harmful of fatal if swallowed" were found unlocked and accessible in the garage; Lysol bathroom cleaner, 2 gallons of windshield washer fluid, and 10 gallons of calcium chloride pellets. Toothpaste containing a label, "contact poison control center if ingested" was unlocked and accessible in the bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | New supervisor has made all poisonous materials inaccessible. Materials are locked in staff room.A new home supervisor has been placed in charge of this home and has been instructed on all regulations, has read assessments on all individuals. She will routinely monitor paperwork along with PS and DSP. When LII are conducted quarterly, home supervisor will report back to Program Director for any violations with a plan of correction. 11/16/2016 |
11/16/2016
| Implemented |
6400.62(c) | Calcium Chloride Pellets were stored in a 5 gallon bucket labeled Keralastic flexible acrylic latex additive. | Poisonous materials shall be stored in their original, labeled containers. | New home supervisor removed the pellets. she has been instructed on regulations and policies.A new home supervisor has been placed in charge of this home and has been instructed on all regulations, has read assessments on all individuals. She will routinely monitor paperwork along with PS and DSP. When LII are conducted quarterly, home supervisor will report back to Program Director for any violations with a plan of correction. 11/16/2016 |
11/16/2016
| Implemented |
6400.72(a) | The front screen door contained approximately a 2 inch rip in the screen near the door handle. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Fixed by maintenance man. Invoice attached.Screen was repaired by HAP Maintenance on 10-13-2016. Invoice attached. |
10/13/2016
| Implemented |
6400.104 | REPEAT from 9/29/15 renewal: When the home notified the fire deparment on 4/11/16, they did not include Individual #1's assistance needed for evacuation. Individual #1 required verbal and physical assistance to evacuate during fire drills since his admission on 4/9/16. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| New letter and diagram were written and sent to acting fire company. Copy attached.A new letter was written to include updated information on individuals living in the home as well as their placement in the home. 10/04/2016. Fire drill books will be reviewed on a quarterly basis to insure all appropriate information is logged and in compliance with the LII. (on-going) A new home supervisor has been placed in this house and has been instructed on all policies and regulations by the Executive Director. 11/16/2016 |
10/04/2016
| Implemented |
6400.113(a) | Individual #1 moved to the residence on 4/9/16 and was not instructed in general fire safety until 4/11/16. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | New supervisor has taken over foe the home. She has been advised on policies, regulations, and protocols.A new home supervisor has been placed in charge of this home and has been properly instructed by the Executive Director on Admission policies for Individuals entering into a group home per HAP Policies. 11/16/2016 |
11/16/2016
| Implemented |
6400.141(c)(14) | Individual #1's 5/18/16 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This field was left blank. A clarficiation was published by the department in April 2015 indicating that it was not permissible to leave blanks on an Individual's physical examination form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Corrected and completed 10/05/2016. copy attached Annual physicals will be completed and reviewed by the PCP. Upon completion of paperwork, Home supervisor will review the documentation, noting any errors and/or blanks and make sure they are corrected by the responsible person. The paperwork will be scanned and submitted to PS who will also review for any errors and/or blanks. Paperwork will again be reviewed according to the LII by all employees to insure accurate documentation is completed. Target date : 02/28/2017 |
10/05/2016
| Implemented |
6400.164(a) | REPEAT from 9/29/15 renewal: Individual #1 was prescribed Loratadine 10mg once per day as needed. Staff #2 initialed Individual #1's medication administration record (MAR) on 10/3/16 and Staff #3 initialed the MAR on 10/4/16 as administering Loratadine but neither indicated a time of administration. The medication label for Individual #1's Visine drops indicated "1-2 drops, 4 times per day." Individual #1's October 2016 MAR did not match the medication label and indicated "1-2 drops as needed" for the Visine drops. Individual #1's Amlactin medication label indicated it was to be applied 1-2 times per day. The October 2016 mar indicated Amlactin was to be applied to feet as needed, not matching the medication label. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | November med log reflects dates, times, and staff initials. Doctor changed Loratidine to 1 time daily on 12/1/16. The medication trainer responsible for maintaining records has been trained in proper record management. She has also trained 2 practicum observers for proper record keeping. Medication logs will be reviewed monthly to insure required documentation is appropriate and accurate. |
12/01/2016
| Implemented |
6400.168(d) | REPEAT from 9/29/15 renewal: Staff #4 completed medication administration training on 8/25/15 and not again until 10/3/16. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | New trainer is n charge of staff practicums and has developed a flow chart to reflect due dates. this person has completed a practicum on a staff member to show it is being completed on time.The Medication Trainer responsible for maintaining these records is no longer employed by the provider. The current Medication Trainer has been trained in the required record keeping of Medication Training, Practicums, and Observations. Upon completion of any and all components of the Medication Training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. |
12/02/2016
| Implemented |
6400.168(e) | The medication observation forms that include dates completed and certification from a medication trainer were not kept for Staff #1 or #5. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | Certificate is on file and attached from 11/19/14 expires 2017.The Medication Trainer responsible for maintaining these records is no longer employed by the provider. The current Medication Trainer has been trained in the required record keeping of Medication Training, Practicums, and Observations. Upon completion of any and all components of the Medication Training, the administrative assistant will scan the signed document into the electronic personnel file system and forward the original to the accounting manager who will include it in the hard copy personnel file. |
12/21/2016
| Implemented |
6400.181(e)(14) | Individual #1's ability to swim was not indicated in his/her 5/21/16 assessment. | 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. | Ability to swim updated in ISP on 10/07/2016. Copy from HCSIS attached.ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. |
10/07/2016
| Implemented |
6400.183(3) | Individual #1's Individual Support Plan (ISP) did not include the method of evaluation used to determine progress towards his/her outcomes to "wash hands," "make bed," and "wipe table." The ISP indicated that once the goal was made, then progress will be determined. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | ISP written indicates a 90% success rate for 3 consecutive months. Plan copied out of HCSIS. Updated 10/07/2016ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. |
10/07/2016
| Implemented |
6400.183(7)(iii) | REPEAT from 9/29/15 renewal: Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | ISP update written and reflects individuals potential. Copy of plan from HCSIS attached.ISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. |
10/07/2016
| Implemented |
6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| ISP plan updated 10/07/2016 to include this. Copy attached from HCSISISP was reviewed and updated with SC. Method of evaluation was placed in plan by SC for a 90% success rate for 3 consecutive months. PS and home supervisor will review plans quarterly to insure paperwork is accurate. Assessments for individuals will be completed by DSP¿s, home supervisor, and PS. PS will review all assessments to follow along with LII regulations to include all components. ISP¿s and reviews will be evaluated quarterly by employees/home supervisors and LII summaries will be turned into Executive director for review. Target date: 02/28/2017 and on-going. |
10/07/2016
| Implemented |
6400.186(b) | Individual #1's Individual Support Plan (ISP) review completed on 9/14/16 was not dated by the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Corrected and completed. December review is attached to show Individual #1 signed and dated.Outcomes and reviews have been reviewed, dated, and signed for Individual #2. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with Individual #1. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. |
10/05/2016
| Implemented |
6400.186(c)(1) | Individual #1's Individual Support Plan (ISP) review completed on 6/13/16 did not review any outcomes. His/Her outcomes to wash hands, make bed, and wipe table were implemented on 5/21/16 and the 6/13/16 ISP review indicated that the outcomes will be reviewed on the next review. | 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. | June 13 stated outcomes for the above mentioned indicated that they would be assessed on the next quarterly for 9/14/2016. Goals were implemented July 2016. these outcomes are reflected on 9 month and 12 month quarterly.Outcomes and reviews have been reviewed, dated, and signed for Individual #1. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with Individual #2. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. |
12/15/2016
| Implemented |
6400.186(c)(2) | Individual #1's 9/14/16 and 6/13/16 Individual Support Plan (ISP) reviews did not include a review of his/her dental plan or his/her seizures and seizure protocol. Individual #1's record contained documentation indicated that he/she had seizures on 9/1/16, 8/21/16, 8/16/16, 5/28/16-5/30/16, 4/12/16, and more. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Individual #1 completed, corrected, and reviewed on 12/15/2016 quarterly. copy attached.Outcomes and reviews have been reviewed, dated, and signed forIndividual #1. Homes will undergo quarterly LII inspections to insure all paperwork is up to date and appropriate documentation is included. Home supervisors along with DSP¿s will conduct inspections and review paperwork with PS. Summaries will be given to Executive Director for review. Target date: 02/28/2017 and on-going. |
12/15/2016
| Implemented |
6400.213(1)(i) | Individual #1's record did not include his/her religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Vita sheet retyped and corrected.Individual #1 vita sheet was rewritten to include religious affiliation. All homes will be checked quarterly via a LII inspection summary to insure all paperwork is accurate. Home supervisors will conduct inspections with DSP and turn paperwork in to Executive Director for review. Target date: 02/28/2017 and on-going |
10/05/2016
| Implemented |