|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The provider is Individual # 1's representative payee and did not have a record of financial resources including withdrawals and deposits. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Administrator, Residential Manager, Financial Officer, CEO
A systematic financial tool (e.g.: balance sheet) indicating beginning and ending balances along with all credits and withdrawals. Halia will maintain all receipts of purchases made on behalf of the individuals that Halia is a representative payee.
Halia has contacted Advocacy Alliance to take over the responsibility of representative from Halia. |
04/30/2016
| Implemented |
| 6400.22(e)(3) | Individual # 1 needs assistance with managing money and the provider is the representative payee. there are no receipts for purchases totally $15.00 or more. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Administrator, Residential Manager, Financial Officer, CEO
A systematic financial tool (e.g.: balance sheet) indicating beginning and ending balances along with all credits and withdrawals. Halia will maintain all receipts of purchases made on behalf of the individuals that Halia is a representative payee.
Halia has contacted Advocacy Alliance to take over the responsibility of representative from Halia. |
04/30/2016
| Implemented |
| 6400.31(b) | Individual # 1 most recent individual rights statement was signed on 02/01/2013. | 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. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance.
[Program Specialist or Program Designee will ensure that Individual #1 receives and signs the individual rights statement within 10 days of receipt of this plan of correction. Quality Assurance or Program Designee will audit the files upon receipt of this plan of correction to determine that all individuals residing in a licensed 6400 home have a current signed statement of individual rights. For anyone who does not have a current signed statement of rights, the program specialist or program designee will ensure that they receive it and have it signed by 9.30.2016. Quality Assurance or program designee will document the date of the most recent signed individual rights statement and keep a file indicating the date and when it will be due in the upcoming year. DD 9.7.16]
|
04/30/2016
| Implemented |
| 6400.64(a) | The washing machine was leaking water resulting in water throughout the basement.
There was a black substance consistent with mold covering the wall in the basement. | Clean and sanitary conditions shall be maintained in the home. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.67(a) | The top hinge of a kitchen cabinet was broken.
There were missing tiles on the basement floor.
| Floors, walls, ceilings and other surfaces shall be in good repair. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.67(b) | a nail approximately three inches in length was found protruding from Individual # 3's bedroom door. | Floors, walls, ceilings and other surfaces shall be free of hazards. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.76(a) | A kitchen chair was broken
The legs on one of the kitchen chairs were loose.
The fabric was peeling on one of the kitchen chairs seat.
A tear approximately one foot in length was found on the back of a wicker chair.
Individual # 1's dresser was missing handles.
Individual # 3's dresser was missing the lower right dresser draw.
| Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, chairs, table, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | a. Administrator, Residential manager,
b. The home have been checked and all items in first aid kit have been replaced.
c. To prevent reoccurrence of non-compliance, HHCS will conduct periodic self-checks, and 6 months checks of all first aid kit to ensure that they are intact ready for emergency. |
04/12/2016
| Implemented |
| 6400.101 | There was a key lock on the basement door. (Repeat Violation 05.16.2014 and 06.23.2015) | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| a. CEO, and Administrator
b. On 04/05/2016, the basement lock was replaced with a locked preventing obstruction in and out of the basement area.
c. To prevent reoccurrence of non-compliance, HHCS will conduct periodic walk-through using a checklist, to ensure that Stairways, halls, doorways, passageways and exits from rooms and from the building remains unobstructed. [Documentation of the removal of the key lock will be send to BHSL within 10 days of receipt of this plan of correction. Quality Assurance or Program designee will audit the checklist quarterly to ensure all non compliance was addressed and all areas of the homes remain in compliance with the regulation. Additionally, documentation of the periodic checklist completed by the HHCS or program designee from April 2016 to September 2016 will be forwarded to BHSL within 10 days receipt of this plan of correction DD 9.7.16] |
04/12/2016
| Implemented |
| 6400.106 | There was no documentation that the furnaces were cleaned. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| a. CEO, and Administrator
b. A professional furnace cleaning company has been secured to serve all furnaces in all homes.
c. To prevent reoccurrence of non-compliance, HHCS will conduct periodic self-checks, and 6 months checks of all furnaces to ensure that they are clean and serviceable with written documentation of the inspection and cleaning records kept on file. |
04/12/2016
| Implemented |
| 6400.112(a) | There were no fire drills to review | An unannounced fire drill shall be held at least once a month. | a. Residential Manager, Administrator, Direct Staff Person
b. Unannounced fire drills will be coordinated and conducted monthly in each home.
c. The residential manager will provide oversight to ensure follow through.
d. All staff have received annual fire safety training,
e. All homes have had fire drills using alternative route other than front door on 04/07/2016.
f. All fire drills records are now kept in the home associated with the drill, and is to be available for review by state license inspector when required.
g. To prevent reoccurrence of non-compliance in this area, HHCS management will develop monthly tracking tool to report and ensure that monthly fire drills are completed. Management will continue to provide trainings annually. |
04/12/2016
| Implemented |
| 6400.113(a) | Individual # 1 did not have annual fire safety training. | 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. | a. Residential Manager, Administrator, Direct Staff Person
b. Unannounced fire drills will be coordinated and conducted monthly in each home.
c. The residential manager will provide oversight to ensure follow through.
d. All staff have received annual fire safety training,
e. All homes have had fire drills using alternative route other than front door on 04/07/2016.
f. All fire drills records are now kept in the home associated with the drill, and is to be available for review by state license inspector when required.
g. To prevent reoccurrence of non-compliance in this area, HHCS management will develop monthly tracking tool to report and ensure that monthly fire drills are completed. Management will continue to provide trainings annually. |
04/30/2016
| Implemented |
| 6400.144 | Individual # 1 is prescribed Keppra 1,000 mg and the 8:00PM dose was not administered 11/24/2015 and 12/27/2015.
Individual # 1 is prescribed Lamictal 150 mg and the 8:00PM dose was not administered 12/27/2015.
Individual # 1 is prescribed Risperdal 1 mg and the 8:00PM dose was not administered on 12/30/2015, 12/31/2015, 02/07/16 and 02/14/16.
Individual # 1 is prescribed Topamax 200 mg and the 8:00AM dose was not administered on 12/31/2015 and the 8:00PM dose was not administered 12/30/2015 and 12/31/2015.
Individual # 1 is prescribed Vimpat 200 mg and the 8:00PM dose was not administered 12/30/2015 and 12/31/2015.
Individual # 1 is prescribed Cogentin 1 mg and the blister pack contained the 8:00PM dose was not administered on 02/18/16 and 02/19/16. Staff initialed the medication administration record for those days indicating it was administered.
Individual # 1 is prescribed Risperdal 1 mg and the blister pack contained the 8:00PM dose 02/18/16 and 02/19/16. Staff initialed the medication administration record for those days indicating it was administered.
Individual # 1 is prescribed Risperdal 0.5mg and the 8:00PM dose was not administered 02/28/2016 and 02/29/2016.
Individual # 1 is prescribed Cogentin 0.5 mg the 8:00PM dose was not administered 02/28/2016 and 02/29/2016.
Individual # 1 is prescribed Flonase .05% nasal spray daily and it was not administered on 02/12/16 and 02/13/16.
Individual # 2 is prescribed Haldol 5 mg and the 8:00Pm dose was not administered on 02/14/2016.
Individual # 2 is prescribed Lipitor 40 mg and the 8:00PM dose was not administered on 02/14/16 and 02/21/16.
Individual # 2 is prescribed Prilosec DR 40 mg and the 8:00PM dose was not administered on 02/14/2016.
Individual # 2 is prescribed Motrin 600mg PRN and it was not in the medication box.
Individual # 2 is prescribed Ultram 50 mg PRN and it was not in the medication box.
Individual # 3 is prescribed calcium 600 mg and the 8:00PM dose was not administered on 02/14/2016
Individual # 3 is prescribed calcium 600 mg and the 8:00am dose was not administered on 11/22/2015.
Individual # 3 is prescribed cerovite and the 8:00am dose was not administered on 02/19/16 and 02/20/16.
Individual # 3 is prescribed Depakote ER 500mg and the 8:00pm dose was not administered on 02/14/16 and 02/21/2016.
Individual # 3 is prescribed Fish Oil and the 8:00pm dose was not administered on 02/14/16 and 02/21/2016.
Individual # 3 is prescribed Vitamin D 400 units and the 8:00pm dose was not administered on 02/14/16.
| Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| a. Nurse, residential manager, and Administrator
b. Halia has taken steps by contracting services of LPN part-time worker who is responsible for follow-ups, and monitoring staff in their responsibility of administrating medication. The residential manager will conduct weekly checks, while the Administrator provides general oversight.
c. (Attachment #2)
d. Halia plans to complete training of all staff. In the future, Halia management will continue to conduct trainings annually, and conduct on-going on-site monitoring to prevent reoccurrence. Halia further promised to change methods and practices that violate proper medications administration, and will implement proactive approach to avoid future recurrences. |
04/12/2016
| Implemented |
| 6400.161(b) | Individual # 1 is prescribed Lac Hydrin 12% Lotion and it was stored in the upstairs closet.
Individual # 1 was prescribed Colace which was discontinued on 01/19/2016 and it was found in a cabinet.
| Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | a. Administrator, agency nurse, and residential manager
b. Halia Home Care recognizes the importance of securing the individual¿s records, and is committed to preserve the privacy, confidentiality, and security of all records including the MAR associated with the individuals we service.
c. The residential manager will ensure that this correction is maintained. has taken the following measures to properly secure Individual #1 and all other individuals¿ medication administration records: are kept in a locked cabinet: All staff assigned in the home will receive on-site training on how to securely keep the individual MAR, and the residential manager is responsible to monitor and ensure that staff follow through with these measures. The Administrator will also conduct weekly monitoring of the home. Halia Home Care has obtained and dedicated a cabinet with lock and keys located in a secure area for the purpose of keeping all medication administration records when unattended. |
04/30/2016
| Implemented |
| 6400.161(e) | Detrol 4mg expired on 11/2014 and was found in Individual # 2's medication box. | Discontinued prescription medications shall be disposed of in a safe manner. | a. Administrator, residential manager
b. Individual medications have been inserted in the MAR
c. All medications have been rescheduled for drop-off at Halia¿s mean office for initial review
d. Medications and MAR received from the pharmacy will be reviewed by the Administrator prior to certify that all medications matched the prescription sllabel and are accounted for on MAR before sending them off to the homes.
e. The Administrator will provide ongoing monitoring, and training of staff to report any and all discrepancies.
f. Moving forward, Halia¿s Administrator will conduct monthly reviews of all MARs to avoid a repeat of medication not listed on MAR. If any discrepancy is found on the MAR and/or prescription slip, the Administrator/staff will communicate with the doctor/pharmacy to correct the discrepancy. |
04/12/2016
| Implemented |
| 6400.162(a) | Individual # 1 is prescribed Lac Hydrin 12% Lotion and it did not have prescription label.
The prescription label on a medication located in Individual #1's medication box was illegible.
| The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | a. Administrator, residential manager, and nurse
b. Individual #1 medications have been inserted in the MAR
c. All medications have been rescheduled for drop-off at Halia¿s mean office for initial review
d. Medications and MAR received from the pharmacy will be reviewed by the Administrator prior to certify that all medications matched the prescription label and are accounted for on MAR before sending them off to the homes.
e. The Administrator will provide ongoing monitoring, and training of staff to report any and all discrepancies.
f. Moving forward, Halia¿s Administrator will conduct monthly reviews of all MARs to avoid a repeat of medication not listed on MAR. If any discrepancy is found on the MAR and/or prescription slip, the Administrator/staff will communicate with the doctor/pharmacy to correct the discrepancy. |
04/30/2016
| Implemented |
| 6400.164(a) | Mucinex DM and Motrin PM were not listed on Individual # 1's MAR and were found in Individual #1¿s medication box. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | a. Administrator, residential manager
b. Individual #1 medications have been inserted in the MAR
c. All medications have been rescheduled for drop-off at Halia¿s mean office for initial review
d. Medications and MAR received from the pharmacy will be reviewed by the Administrator prior to certify that all medications matched the prescription sllabel and are accounted for on MAR before sending them off to the homes.
e. The Administrator will provide ongoing monitoring, and training of staff to report any and all discrepancies.
f. Moving forward, Halia¿s Administrator will conduct monthly reviews of all MARs to avoid a repeat of medication not listed on MAR. If any discrepancy is found on the MAR and/or prescription slip, the Administrator/staff will communicate with the doctor/pharmacy to correct the discrepancy. |
04/12/2016
| Implemented |
| 6400.168(a) | Staff # 7 administered medications in February 2016 and did not complete the Department's Medication Administration course. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | a. Administrator, Residential Manager, Program Specialist and CEO
b. Staff#7 completed DMA initial training and observation on 01/16/2016. Staff who did complete the DMA training has been prevented for passing out meds.
c. Halia will continue to maintain records and review them to ensure that staff is certified before assigning them to administer medications.
d. Halia has developed a tracking tool to ensure all staff are current/up-to-date with the Department's Medication Administration annual practicum.
e. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
f. Maintain consistency with licensing regulations, schedule staff for all trainings that are due.
g. Update the training log with date of completion for all completed. |
04/12/2016
| Implemented |
| 6400.168(d) | Staff # 1 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 1 previously completed the Department's medication administration training course on 07/18/2013.
Staff # 2 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 2 previously completed the Department's medication administration training course on 11/07/2014.
Staff # 3 administered medications in February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 3 previously completed the Department's medication administration training course on 10/08/2014.
Staff # 4 administered medications in November 2015, December 2015, and January 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 4 previously completed the Department's medication administration training course on 07/18/2013.
Staff # 5 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 5 previously completed the Department's medication administration training course on 11/07/2014.
Staff # 6 administered medications in January 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 6 previously completed the Department's medication administration training course on 11/13/2013.
| A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | a. Administrator, Residential Manager, Program Specialist and CEO
b. Staff#1, 2, 3, 4, 5, and 6 completed DMA initial training and observation on 01/16/2016. Staff who did complete the DMA training has been prevented for passing out meds.
c. Halia will continue to maintain records and review them to ensure that staff is certified before assigning them to administer medications.
d. Halia has developed a tracking tool to ensure all staff are current/up-to-date with the Department's Medication Administration annual practicum.
e. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
f. Maintain consistency with licensing regulations, schedule staff for all trainings that are due.
g. Update the training log with date of completion for all completed. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(i) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(ii) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(iii) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/30/2016
| Implemented |
| 6400.181(e)(13)(iv) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of personal adjustment | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(v) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of socialization | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(vi) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(vii) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(viii) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of managing personal property | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(13)(ix) | Individual # 1's annual assessment dated 11/05/2015 did not document progress and growth in the area of community integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.181(e)(14) | Individual # 1's annual assessment dated 11/05/2015 does not document the individual¿s ability to swim | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/12/2016
| Implemented |
| 6400.186(a) | Individual # 1's most recent 3 month ISP review documentation was dated 03/28/2015. | 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. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/30/0201
| Implemented |
| 6400.186(c)(1) | Individual # 1's most recent monthly documentation was dated May 2015. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1¿s book to reflect all progress on outcomes, and goals.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, and lifetime Medical) current, and has taken the following steps to ensure that the program specialist complete an ISP review, update expected outcomes agreeing with the 6400 regulations.
d. Moving forward, the program specialist will ensure update records and maintain the individual ISP current. The program specialist will make monthly report of all quarterlies, updated ISP, assessment, etc. for administrator¿s final review. The Administrator will conduct weekly monitoring of the home. The program specialist will have training in his/her responsibilities, and will continue to receive on-going trainings in order to avoid a repeat of this non-compliance. |
04/30/2016
| Implemented |
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