| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed between 3/19/23 and 3/24/23. The agency certificate of compliance expires 10/18/23 and the last renewal inspection was completed 4/27/22. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A self-assessment will be completed at least annually within the 3¿6-month time frame set forth in the 6400 regulations. The Self-Assessment Forms will be prepared by the Program Manager annually in April and are then scheduled to be completed in a timely manner to allow for corrections to be made and follow-up inspections to occur within the time frames. |
04/28/2023
| Implemented |
| 6400.66 | On 4/10/23, the light fixture outside of the man door in the garage was found inoperable at 12:04 PM. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The Maintenance Supervisor checked the lightbulb in the fixture and found that a lightbulb made for a dimming switch was required. The correct type of lightbulb was placed in the light fixture which is now operable on 04/20/2023. |
04/20/2023
| 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 month of October 2022. | 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.
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04/25/2023
| Implemented |
| 6400.113(a) | Individual #1, date of admission 8/31/22, completed fire safety training 9/5/22. Individual #2, date of admission 6/3/22, completed fire safety training on 9/5/22. | 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. | 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 that the Fire Safety Training and Fire Evacuation Procedure have been reviewed, completed and signed by the individual and that an unannounced Fire Drill has taken place on the day of move-in. The intake forms will be reviewed by the Program Manager on the day of admission for completion. |
05/31/2023
| Implemented |
| 6400.141(c)(11) | Individual #2' physical examination completed on 3/30/22 did not address the need for routine bloodwork at recommended intervals. This field was left blank on the form. [Repeated Violation 4/26/22, et al] | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Agency Nurse will contact the PCP to request recommendation related to the missing information and follow-up as recommended. |
05/31/2023
| Implemented |
| 6400.141(c)(15) | Individual #1's physical examination completed 3/10/23 did not address special instructions regarding their diet. This section was left blank on the form. | The physical examination shall include:Special instructions for the individual's diet. | The Agency Nurse will contact the PCP to request recommendation related to the missing information and follow-up as recommended. |
05/31/2023
| Implemented |
| 6400.142(a) | Individual #1's most recent dental examination was completed 8/4/21. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Program Specialist will be re-trained on required documentation upon intake for individuals and proper documentation of missing information, known barriers to any services or required annual appointments and the steps being taken to remedy the situation. The individual did not have dental insurance when they were admitted to the program. The Program Specialist worked with the Individual Plan Team as well as the Social Security office and previous providers to assist in getting the individuals documents corrected so that they could obtain the proper insurance coverage and funding needed. The individual has an annual dental exam scheduled for August 22, 2023 and is on a cancellation waitlist to possibly get an earlier appointment. |
05/31/2023
| Implemented |
| 6400.181(a) | Individual #1, date of admission 8/31/22, had an initial assessment was completed on 2/20/23. [Repeated Violation 4/26/22, et al] | 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. | 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 the due date of the initial Independent Living Assessment (ILA) 60 days from the admission date. |
05/31/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's 2/20/23 assessment did not address their preferences. Individual #2's 3/20/23 assessment did not address their 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 2/20/23 assessment did not address their likes, dislikes, and interests. Individual #2's 3/20/23 assessment did not address their interests. | 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 2/20/23 assessment did not address their ability to evacuate during a fire. Individual #2's 3/20/23 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.
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05/31/2023
| Implemented |
| 6400.34(a) | Individual #1, date of admission 8/31/22, was not informed and explained individual rights. [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.
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05/31/2023
| Implemented |
| 6400.46(a) | Temporary Direct Support Professional #1, date-of-hire is 10/28/22, 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.
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05/31/2023
| Implemented |
| 6400.165(f) | Individual #2 is prescribed psychotropic medication. Their record did not include a plan to address their social, emotional, and environmental needs relative to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The SEEP plan for this individual was finalized on 04/05/2023 by the Provider's Behavior Specialist. |
04/05/2023
| Implemented |
| 6400.165(g) | Individual #2 was admitted on 6/3/22 and is prescribed psychotropic medication. Their record contained documentation that a licensed physician had only conducted reviews of this prescribed medication on 11/1/22 and 12/1/22. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Quarterly appointments to review psychotropic medications will be tracked in the Electronic Health Record (EHR) Appointment Tracking system. Notifications for quarterly appointments will be set as high priority within the system to notify the team when the appointments are upcoming. Any appointment that is missed, cancelled, rescheduled or refused will be tracked in the system as well and appointment refusal forms will be completed by the Program Specialist and reviewed with and signed by the individual to be uploaded and attached to the appointment in the EHR system. |
05/31/2023
| Implemented |
| 6400.166(a)(11) | The Medication Administration Record for April 2023 for Individual #1 did not list the diagnosis or purpose for the prescribed Tretinoin Cre 0.25%, Omeprazole Cap 20 MG, Clindamycin 1% Pledgets, and pro re nata, Docosanol Cre 10%. The Medication Administration Record for April 2023 for Individual #2 did not list the diagnosis or purpose for the prescribed Senna-Tabs Tab 8.6 MG, Gabapentin Cap 300 MG, Diclofenac Gel 1%, Citalopram Tab 40 MG, Citalopram Tab 20 MG, Xiidra Dro 5%, Vitamin D Tab 50 mcg, Lubricating Sol Tears, Eye Allergy Sol Itch Rel., and Allopurinol Tab 10 MG. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Medication Administration Records(MARs) for both individuals have been updated to indicate the diagnosis or purpose of the medications identified during the review. The Provider Nurse also completed an audit of MARs for all other individuals served and updated MARs to reflect diagnoses or purpose as needed. |
04/18/2023
| Implemented |
| 6400.181(f) | Individual #1's admission date is 8/31/22. Their initial assessment completed on 2/20/23 was sent to the individual plan team members on 2/20/23 for an individual plan meeting held on 2/23/23. [Repeated Violation---5/4/21, 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 |
| 6400.183(c) | Individual #2's record did not contain an attendance list of the members who had participated in the individual plan annual review meeting held on 8/2/22. | The list of persons who participated in the individual plan meeting shall be kept. | The Program Specialist will request a copy of the attendance signature page from the individual's current Support's Coordinator. The annual review meeting was held virtually an the attendance confirmation list was not sent to the team. The attendance signature page will be uploaded to the individual's electronic records upon receipt. |
05/31/2023
| Implemented |