| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(b) | Training non-compliant-initial fire safety training was not provided at inspection, current 10/24/20. | If an individual is medically or functionally unable to participate in the fire safety training, documentation shall be kept specifying why the individual could not participate. | Annual fire safety training for this individual was not completed on time due to COVID-19 risk mitigation protocols in place at the time it was due. Individual Fire Safety Training was completed in October 2020 for all persons accepting support and October chosen as Values Into Action¿s Fire Safety Month; moving forward all individuals will receive annual fire safety training during this month to ensure ongoing compliance with receiving annual fire safety training. Service Director also located this individual¿s initial fire safety training documentation and has ensured it is stored in the individual¿s file. Ongoing compliance will be monitored by Service Director. |
12/22/2020
| Implemented |
| 6400.181(a) | Assessment non-compliant-initial assessment was completed on 5/12/19, annual assessment was completed 12/7/19. Only 7 months passed between initial and current assessment. It could not be determined the progress for the last year. | 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. | Values Into Action¿s Service Director, Clinical Support Director, and Program Specialist have created a new tracking system to ensure that each individual supported has a timely annual assessment, based on his/her initial assessment date. Timeframes were corrected and Program Specialist will continue to use the corrected tracking system to ensure ongoing compliance with annual assessments moving forward for all individuals supported. Service Director will complete periodic reviews of assessments to ensure ongoing compliance.
Attachment 8: Copy of Tracking System for Service Documentation Timelines |
12/22/2020
| Implemented |
| 6400.166(b) | Individual #1's medications for 7 AM on 11/18/2020 were not logged at the time of inspection.
These medications are:
Keppra 1000 mg
KCL ER 10 meq
Polyethylene Glycol 3350
Enulose 10 gm/15 ml
Fluticasone Nasal Spray
Combigan
Artificial Tears | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Medication Administration Record (MAR) documentation error was corrected and verified by Values Into Action Service Coordinator. Staff received retraining on proper MAR documentation on 11/18/2020. Values Into Action Service Coordinator and Clinical Support Director have created MAR documentation system via Therap (online medical record/documentation system) and will ensure all staff are trained on the new system for implementation as of 2/1/2021. New e-MAR system will allow Service Coordinator to complete remote oversight of MAR documentation moving forward to immediately identify and address any MAR documentation issues/concerns for all individuals supported with medication administration.
Attachment 9: Memo regarding staff re-training
Attachment 10: Copy of e-MAR |
11/18/2020
| Implemented |