| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist was not completing the assessments for the individuals. A direct support staff, who did not have program specialist qualifications, was completing the assessments. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | Who: Program Coordinator (Specialist by regulations)
What: complete the annual assessment in whole.
When: Within 60 days for a new admission, annually per regulations, or when a critical revision meeting is needed for modification of services.
How: PC¿s were retrained in these duties. The Program Coordinator (Specialist by regulations) must complete all aspects of the assessment. At this time, the monthly outcome progress form has been revised. The RPS will complete the monthly outcome progress form. The Program Coordinator will utilize this form, in addition to the other paperwork that is completed on a daily basis and speak with staff that work with the individual to complete the assessment in whole. The PC will also utilize the Yearly Progress form that was created in 2015 as part of the plan of correction.
Attachment:
¿ Signature sheet from RPS meeting (attachment #10)
¿ RPS meeting Agenda (attachment #11)
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of assessment that was fully completed by the PC only (attachment #13) |
09/19/2016
| Implemented |
| 6400.67(a) | The sink in the bathroom upstairs did not drain. Water filled to the overflow spout of the sink. There was approximately a 1 foot diameter chunk of cement missing from the back porch exit. The screens in the back porch were off their tracks; some of them hanging from the window panel. | Floors, walls, ceilings and other surfaces shall be in good repair. | Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3)
¿ Email from property manager stating that the work was completed. The work was verified by the ADOS. (attachment # 4)
¿ Completed Administrative Regulation Monitoring form that was updated.(attachment # 5) |
09/19/2016
| Implemented |
| 6400.67(b) | There were 7 small but noticible shards of glass on the back porch exit walkway. There were 10 large shards of glass in the flower bed to the left of the back porch exit door. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3)
¿ Letter from RPS stating that they cleaned the glass up (attachment # 6)
¿ Completed Administrative Regulation Monitoring form that was updated. (attachment #5)
¿ Letter to individual that resides at the home that was destroying and vandalizing the property. Letter is documentation that informs individual of possible discharge if property destruction continues (attachment # 7 ) |
09/19/2016
| Implemented |
| 6400.72(b) | The screen on the basement door exit had a 1'6" rip at the bottom and a 6" rip on the right side of the screen. | Screens, windows and doors shall be in good repair. | Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all surfaces are in good repair and are free from hazards, as per Ch. 6400 regulation 67.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment #3 )
¿ Email from property manager stating that the work was completed. The work was verified by the ADOS. (attachment # 4)
¿ Completed Administrative Regulation Monitoring form that was updated.(attachment # 5) |
09/19/2016
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not include staff and individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Who: Assistant Director of ID Services
What: Updated the form to include all regulatory requirements.
When: After form was found to be out of compliance with regulations.
How: Form was updated after licensing. All staff and individuals were trained in their responsibilities in the event that an evacuation must occur at one of the group homes. A copy of the form that was individualized for each individual, was placed in the individual¿s records at the home.
Attachments:
¿ Copy of the Emergency Relocation Plan for each individual (attachment # 1)
¿ Signature showing that all staff and all individuals were trained in their responsibility (attachment # 2) |
09/19/2016
| Implemented |
| 6400.112(a) | The date of the next fire drill is announced to all staff a month in advance. | An unannounced fire drill shall be held at least once a month. | Who: Assistant Program Coordinator or in APC;s absence, the Client Advocate
What: Implement new procedure in which the APC (or CA in the APC¿s absence) calls the group home to inform staff that a fire drill must be completed.
When: Monthly as per regulations, or more frequently if needed (i.e.,
How:
1. Staff at the homes will no longer determine when a fire drill will be completed.
2. Officer personnel (either Assistant Program Coordinator responsible for tracking fire drill forms, in addition to the furnace testing, the well water checks and the weekly and monthly egress forms OR in their absence, the Client Advocate) will call the home and state: You MUST completed a fire drill at this time.
3. The staff at the home who answered the phone will then be responsible to complete an UNANNOUNCED fire drill at that time.
4. The staff will also be responsible to complete all required documentation (fire drill form and egress form) and submit this paperwork to the APC within 24 hours.
5. If staff fails to conduct the unannounced fire drill, disciplinary action will be taken, including receiving an employee reprimand for insubordination, in addition to other disciplinary action if the program is out of compliance with chapter 6400 regulations as a result of the staff¿s failure to do as directed. Disciplinary action can be an employee reprimand, suspension, or termination.
6. As per the BSHL Representatives, all individuals do not have to be present at the home during a fire drill.
7. In the event that an individual refuses to evacuate, the individuals do not make it to the meeting place or the 2 ½ minute timeframe is exceeded, the Program Coordinator must be informed, in addition to the APC/Client Advocate, as they will have to call again to repeat this process until a fire drill is successfully completed. Notification must be made as soon as possible, but no later than 24 hours after the unsuccessful fire drill.
Attachments:
¿ Signature sheets showing all staff were trained in POC. (attachment # 8)
¿ Copy of fire drills that were completed in August in which the POC was implement (attachment # 9 )
¿ Signature sheet from RPS meeting (attachment #10) |
09/19/2016
| Implemented |
| 6400.186(a) | The program specialist is not completing the individual's Individual Support Plan (ISP) reviews. A direct support staff, who does not possess program specialist qualifications, is completing the reviews. | 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. | Who: Program Coordinator (Specialist by regulations)
What: Complete the quarterly review of the ISP¿s in whole
When: ongoing ¿ every 3 months after the start date of an individual¿s ISP
How: The Program Coordinator (Specialist by regulations) must complete all aspects of the quarterly reviews. At this time, the monthly outcome progress form has been revised. The RPS will complete the monthly outcome progress form. The Program Coordinator will utilize this form, in addition to the other paperwork that is completed on a daily basis and speak with staff that work with the individual to complete the quarterly review form in whole.
Attachments:
¿ Signature sheet from RPS meeting (attachment #10)
¿ RPS meeting Agenda (attachment #11)
¿ Letter that PC¿s signed to verify that they were retrained in regulations and expectations. (attachment #12)
¿ Copy of quarterly review that was fully completed by the PC only (attachment #14) |
09/19/2019
| Implemented |