| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #3 was informed of his Individual Rights on 1/2/2015. He wasn't informed of his Individual Rights again until 3/1/2016, which exceeds the annual requirement. | 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. | The Program Specialist will be trained by the Deputy CEO on 31 b Regulation standards and practices by 11/5/16. The Program Specialist will be responsible to ensure that the individual is fully aware of his rights and that the Individual's rights form is fully explained. The Program Specialist will also review and verify that the individual signs and date the Individual Rights Form upon admission in the program and thereafter annually. |
11/05/2016
| Implemented |
| 6400.112(e) | From 8/14/2015 to 8/28/2016, no overnight/sleep drills were held at this residence. | A fire drill shall be held during sleeping hours at least every 6 months. | The Residential Supervisor will re-train the Senior Direct Support Professional by 11/5/16 on regulation 6400.112e as it pertains to the completion of overnight fire drills every 6 months . Training will also include a review of the fire drill record form and fire drill submission and tracking process. Senior Direct Support Professionals will submit all complete fire drills, including those completed on the overnight shift immediately after the drill is conducted. The Residential Supervisor will review and monitor the completed fire drill form on a monthly basis to ensure that the overnight fire drills are completed every 6 months as specified in the regulation (attachment b)
(A successful sleep fire drill was conducted on 10/17/16 at 12AM) - CH 11/22/16
|
11/05/2016
| Implemented |
| 6400.141(c)(9) | The physical examination for Individual #3 dated 6/10/16 did not include the results of a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The Program specialist will be trained by the Deputy CEO on regulatory and best practice standard regarding prostate exam for men 40 years of age and older by 10/31/16. The Program Specialist will ensure that all section in the annual physical form are completed, reviewed and signed by the primary physician at the time of the annual physical appointment. Additionally, should the individual refuse his prostate exam at his annual physical, the primary physician will write a script indicating that attempt was made to complete the prostate exam but that the individual refused. A second medical appointment will be scheduled with the urologist with a plan for sedation for a prostate exam provided the family and team are in agreement. The Program Specialist will put in place a plan of desensitization for this exam to assist the individual in tolerating the procedure. Continued counseling and support on prostate appointments will be given to the individual.
(On 11/18/16 Individual #3 was seen by his PCP to attempt a prostate examination. Individual #3 refused the prostate examination. A desensitization plan was put into place. Keystone Human Services is awaiting further follow-up information from the PCP) - CH 11/22/16 |
10/31/2016
| Implemented |
| 6400.141(c)(15) | Individual #3 is diagnosed with Diabetes Mellitus and Dysphagia. He follows an ADA diet. His food must be ground and his drinks thickened to nectar consistency with Thick-It. This information is not included on his physical exam dated 6/10/2016. | The physical examination shall include:Special instructions for the individual's diet. | The Deputy CEO will train the Program Specialist by 11/5/16 in ensuring that annual physical forms include dietary instructions for the individuals diet. The Program Specialist will review each individual's annual physical form for completeness and accuracy and ensure that the individual diet is included in the annual physical form to ensure all required information is completed including special instructions for the individual's diet and immediately obtain the missing information. |
11/05/2016
| Implemented |
| 6400.186(a) | Individual #3 had ISP reviews completed on 10/5/15, 1/11/16, 5/24/16, and 7/7/16. The time period between 1/11/16 and 5/24/16 exceeded the required 3 months. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The Program Specialist will be trained by the Deputy CEO on regulatory and best practice standards, including work process time frames by 10/31/16. The Deputy CEO will monitor by reviewing the Program Specialist spreadsheet which documents on going performance monitoring utilizing a spreadsheet that documents the ISP Review, ISP meeting date, and dates of assessment. Additionally, the Program Specialist will enter ISP related task dates to his outlook calendar, which will be reviewed by the Deputy CEO as a function of the Program Specialist supervision ( attachment a) |
10/31/2016
| Implemented |
| 6400.186(b) | Individual #3 and the Program Specialist did not sign the ISP reviews dated 1/11/16 and 7/7/16. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The Program Specialist role in regards to ISP review process is being clarified by a training conducted by the Deputy CEO by 10/31/16. The Program Specialist is responsible for ensuring that all ISP related documentation is thoroughly and correctly completed, including signatures and dates. The Deputy CEO will provide quality performance reviews of ISP related documentation conducted by the Program Specialist on a quarterly basis and provide performance feedback in ongoing supervision meetings. |
10/31/2016
| Implemented |
| 6400.186(c)(2) | Reviews of ISP areas such as health and safety are not being completed in the ISP Reviews for Individual #3. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The Program Specialist will be trained by the Deputy CEO on regulatory and best practice standings in completing all areas in the ISP by 10/31/16. The Program Specialist will review the ISP to ensure that all relevant information and sections are completed. Additionally, The Program Specialist will follow up with the Supports Coordinator via email and/or agency letter to make all necessary corrections. |
10/31/2016
| Implemented |