| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | On 4/7/23, the game room door leading to the attached garage has a lock requiring a key to open it from inside the garage. There is no man door leading from the garage to the outside of the home, this causes a potential entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Maintenance Supervisor had a locksmith come to the residence to adjust the doorknob and re-key it so that the keyed side of the knob is on the interior of the home and eliminates the entrapment risk in the garage. The door is now able to be unlocked from inside the garage to allow entry into the home. |
04/19/2023
| Implemented |
| 6400.112(a) | According to the written fire drill record submitted for the last 12 months, there were no fire drills held during the following months of 2022: April, May, June, August, and October. | An unannounced fire drill shall be held at least once a month. | The Residential Team Lead Supervisor (RTLS) will re-train the Direct Support Supervisors (DSS) and Direct Support Mentors (DSM) on the ODP Fire Drill 6400.112a-112h regulations and the Provider's policy on Fire Drills. The training will review the requirements and importance of completing the monthly fire drills at each service location. The RTSL will review the current monthly Fire Drill plan including how he will communicate assigned responsibilities for monthly fire drills, dates for completion and timely submission of paperwork to the team. |
04/25/2023
| Implemented |
| 6400.112(e) | According to the written fire drill record submitted for the last 12 months, there were no sleep fire drills held during a 7-month time period from April 2022 to October 2022. A fire drill was conducted during sleeping hours on 5/31/22, but no individuals had been present to participate. | A fire drill shall be held during sleeping hours at least every 6 months. | The Residential Team Lead Supervisor (RTLS) will develop an internal monthly schedule for fire drills for the training year that will be shared only with the person assigned responsibility for conducting the drill each month. This internal schedule will include the details on time of day for each month's fire drill to ensure that drills are held during sleeping hours at least every 6 months. |
05/31/2023
| Implemented |
| 6400.141(a) | Individual #1 had physical examinations completed on 7/19/21 and subsequently on 8/12/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual appointments are tracked in an Electronic Appointment Monitoring System within the Electronic Health Record system. Training and transition to this system for the Nurse and Program Specialists began in January 2023 and is ongoing. This system tracks appointments and the status such as Scheduled, Not Scheduled, Completed, Results Pending, Cancelled, Missed, and Declined. Annual appointments will be tracked in this system and the following year's follow-up appointment and/or scheduling reminders will be linked to the previous year. Notifications for annual appointments will be set as high priority within the system to notify the team when annual appointments are upcoming and/or due to be scheduled. |
05/31/2023
| Implemented |
| 6400.151(a) | Temporary Direct Support Professional #1, date-of-hire is 10/25/22, did not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The temporary worker has not worked a shift for this Provider since 03/29/2023. The temporary worker was notified on 03/29/2023 that they are blocked from picking up any shifts from the Provider until they complete and provide documentation of a physical examination. |
03/29/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's 11/30/22 assessment did not address their strengths and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The Program Specialists will be re-trained by the Program Manager on completing each section of the Independent Living Assessment (ILA) and completing the Strengths and preferences area at the end of each section. They will be re-trained on using information from the previous ILA as well as the current ISP as reference for information to review with the individual to ensure that changes are updated and reported accurately. |
05/31/2023
| Implemented |
| 6400.181(e)(2) | Individual #1's 11/30/22 assessment did not address their dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The Program Specialists will be re-trained by the Program Manager on completing each section of the Independent Living Assessment (ILA) and completing the Likes/Dislikes area at the end of each section. They will be re-trained on using information from the previous ILA as well as the current ISP as reference for information to review with the individual to ensure that changes are updated and reported accurately. |
05/31/2023
| Implemented |
| 6400.181(e)(8) | Individual #1's 11/30/22 assessment did not address their ability to evacuate during a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The Program Specialists will be trained by the Program Manager on the Personal Safety section of the Independent Living Assessment (ILA) and documenting the date of the individuals last completed fire safety training and successful fire drill evacuation at the bottom of the section under the Summary/Progress. They will be re-trained on using information from the previous ILA as well as the current ISP as reference for information to review with the individual to ensure that changes are updated and reported accurately. |
05/31/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 1/19/22 and subsequently on 3/7/23. [Repeated Violation 4/26/22, et al] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Specialists will be re-trained on new admission intake process and documentation requirements. This will include updating the intake checklist form to provide check boxes and a space to document date of completion for each section of the individual consents sections including the Individual Rights Review. The intake forms will be reviewed by the Program Manager on the day of admission for completion. |
05/31/2023
| Implemented |
| 6400.46(a) | Temporary Direct Support Professional #1, date-of-hire is 10/25/22 did not receive fire safety training. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The temporary worker has not worked a shift for this Provider since 03/24/2023. The temporary worker was notified on 03/29/2023 that they are blocked from picking up any shifts for this Provider and if they return in the future they will complete the Provider's Fire Safety Training prior to working with any individuals. The Fire Safety Training will be completed by the temporary workers for all Provider homes prior to working any shift with individuals. The Home Managers will train the temporary workers on the evacuation procedures, responsibilities during fire drills, designated meeting place outside the building, smoking safety procedures, locations of fire extinguishers, smoke detectors and alarms for their assigned homes prior to allowing the temporary worker to work with individuals independently.
|
05/31/2023
| Implemented |
| 6400.181(f) | Individual #1's 11/30/22 assessment was sent to the individual plan team members on 1/29/23 for an individual plan annual review meeting held on 2/1/23. [Repeated Violation 4/26/22, et al] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialists will maintain a spreadsheet of assessment due dates and annual review due dates to ensure that assessments are completed at least 45 days prior to the annual review meetings in order for the internal team to review the information and make necessary updates prior to submitting to the Supports Coordinator and other individual plan team members. The Program Manager and Program Specialists will have a calendar reminder notification scheduled for each individual for 10 days prior to the 30 days submission deadline to ensure that the completed assessments will be sent to the individual plan team members at least 30 days prior to the individual plan meeting. If the individual plan meeting invitation letter is sent out with less than 30 days notice to the team, the Program Specialist will attach documentation of that to the assessment submission if it was not sent prior to receiving the annual review meeting letter. |
05/31/2023
| Implemented |