|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The provider is Individual # 2'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. |
05/13/2016
| Implemented |
| 6400.22(e)(3) | Individual # 2 needs assistance with managing money and is the individual's representative payee. the individual's record does not have 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. |
05/13/2016
| Implemented |
| 6400.31(b) | Individual # 1 dated of admission was 01/05/2016 and there was no individual rights statement signed | 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 program book to reflect progress on goals, that individual sign written consent for release of information, compete and update factsheet/face sheet, photograph to include all identifying information associated with the individual.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, lifetime Medical, etc.) current, and has taken the following steps to ensure that the program specialist review ISP, update expected outcomes/information as agreed upon in the individual¿s ISP.
d. Moving forward, the program specialist will ensure to update records and maintain an updated program book for each individual Halia served. The program specialist will submit to the management/administrator a monthly report of all quarterlies, updated ISP, assessments, etc. for final review. The Administrator will conduct weekly monitoring of the homes; individual¿s program books to maintain consistency. The program specialist will receive on-going trainings in his responsibilities in order to avoid a repeat of this non-compliance item. |
04/30/2016
| Implemented |
| 6400.33(a) | The bathroom shower was broken for two weeks and the individuals residing in the home were told by staff to bath using a bucket filled with water. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | a. Administrator,
b. Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
c. The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
d. To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. |
04/13/2016
| Implemented |
| 6400.33(g) | Individual # 1 was told by staff overnight visitors are prohibited. | An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. | a. We acknowledged that Individual#1 desires to have his girlfriend sleep over, but there is no mention of it in his ISP that he can have overnight visitors in the home. However, he is allowed to spent weekends overnight at this girl¿s home. Helia is working the SC, his mother and SC supervisor to give consideration to he request, while taken into to account the privacy and feelings of his housemates, and liability. |
04/13/2016
| Implemented |
| 6400.33(i) | Individual # 1 stated staff opens his mail. | An individual has the right to unrestricted mailing privileges. | a. This issue has since been resolved, the report was brought to management attention in (January 2016), and actual event was not verified at the time. Halia staff is trained and made aware not to open individual mail. [The Program Director will meet monthly with all of the Individuals living at this home to ensure that they are receiving their mail as delivered, starting within 30 days of receipt of this plan of correction. SW 2.3.17] |
04/13/2016
| Implemented |
| 6400.46(a) | Staff # 1's date of hire was 05/15/2015 and was not oriented to their responsibilities, the daily operation of the home and policies and procedures of the home. (Repeat Violation 06.23.2015) | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | a. Administrator,
b. Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
c. The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
d. To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. |
04/13/2016
| Implemented |
| 6400.46(c) | The CEO had 11.75 hours of annual training for the training year of 09/01/2014-08/31/2015. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Administrator, CEO
In addition to 11.5 hours of training, the CEO has 12 hours of continuing education credits in ID Understanding Communication series: Demystifying Autism(3/29-30/16), and 2hrs of Adult CPR/AED (3/4/2016)
Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. |
04/30/2016
| Implemented |
| 6400.46(h) | Staff # 1's date of hire was 05/15/2015 and there was no documentation to indicate they were trained in first aid techniques. (Repeat Violation 06.23.2015) | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | a. Administrator,
b. Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
c. The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
d. To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. |
04/30/2016
| Implemented |
| 6400.46(i) | Staff # 1's dated of hire was 05/15/2015 and there was no documentation to indicate they were trained in CPR and first aid. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | a. Administrator,
b. Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
c. The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
d. To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. [The Program Director will conduct bi-annual audits of all staff records to ensure that training on CPR/FA is current, starting within 30 days of receipt of this plan of correction. SW 2.3.17] |
04/30/2016
| Implemented |
| 6400.62(a) | Heavy Duty Oven cleaner which indicated to contact a physician if ingested was found unlocked under the kitchen sink. Individual # 4 who was visiting the home can not handle poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.64(a) | There was a black substance consistent with mildew around the tub and tiles in the
bathroom.
The basement floor was covered in a brown substance consistent with dirt.
| Clean and sanitary conditions shall be maintained in the home. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.66 | The lightening in the basement was not operable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.67(a) | There was a hole approximately one foot by one foot in the wall behind Individual #3's bedroom door
There were approximately five missing ceiling tiles in the basement.
The handrail for the staircase leading to the basement was broken.
| Floors, walls, ceilings and other surfaces shall be in good repair. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.69(b) | Individual #1 reported there was no heat in the bedroom for two weeks. | The indoor temperature may not be less than 58°F during sleeping hours. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.73(a) | The handrail for the staircase leading to the basement did not extend the length of the staircase leaving approximately four stairs without a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.76(a) | The lamp in Individual #3's bedroom did not have a lamp shade.
The overhead light in Individual# 3's bedroom did not have a cover.
There were two handles missing from the dresser in Individual # 3's bedroom
a golf ball size amount of lint found in the dryer.
| Furniture and equipment shall be nonhazardous, clean and sturdy. | a. a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.76(b) | The living room furniture consistent of one couch and one coffee table. | Furniture and equipment shall be appropriate for the age and size of the individuals. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) [The Program Director will conduct monthly walk-through of the home to ensure that it is in good repair and homelike for the individuals residing in the home, starting within 30 days of receipt of this plan of correction. SW 2.3.17] |
04/13/2016
| Implemented |
| 6400.77(b) | The first aid kit was missing a thermometer and 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. Residential manager, and Direct staff
b. Halia management has ensure that all replacement of first aid kit and all required items secured and equipped. To prevent reoccurrence of non-compliance in this area, HHCS management will develop weekly tracking tool (monthly/weekly site checklist) to report and ensure all furniture, equipment and first aid kit are in working condition. |
04/30/2016
| Implemented |
| 6400.81(k)(3) | Individual # 3's bed did not have a pillow, linens or a blanket. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has purchased new comforters and two pillows for Individual #3.
c. Administrator and residential manager are responsible to report if any pillow is missing and request for replacement of beddings, pillows, bed sheets, bedroom furnishers.
h. 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. |
04/13/2016
| Implemented |
| 6400.82(f) | The bathroom did not have toilet paper | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) |
04/13/2016
| Implemented |
| 6400.84(b) | Individual # 3's clean clothing was in a pile on the basement floor. | Clean laundry shall be stored in an area separate from soiled laundry. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has repaired, replacing all broken items, rearranged and put away all individual¿s clean clothing: (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.
c. 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.
d. 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) [The Program Director will conduct monthly inspections of the home to ensure that the Individuals clothing is clean and available in their rooms away from soiled laundry, starting within 30 days of receipt of this plan of correction. All staff of the home will receive training on the importance of keeping laundry separate. SW 2.3.17] |
05/13/2016
| 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. |
05/13/2016
| Implemented |
| 6400.112(a) | There were no fire drill records available 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. |
05/16/2016
| Implemented |
| 6400.113(a) | Individual # 1's date of admission was 01/05/2016 and there was no documentation of fire safety training upon admission. | 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. |
05/13/2016
| Implemented |
| 6400.144 | Individual # 3 is prescribed Norvac 5mg and Synthyroid 50 mcg and the medications were not available at the home. Norvac was not given in the month of February, 2016. | 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. Residential manager, Administrator, Agency nurse
b. Halia¿s management immediately addressed missing medication. Individual#3 was taken to his PCP, and he was reordered Norvac 5mg and Synthyroid 50 mcg and the medications. issue of securely disposing of discontinued medications.
c. Halia has established a policy that addresses medication disposal process. All staff will receive ongoing training on how to ensure safe methods of disposal or destroying of medication. Halia¿s policy states that all discontinued and expired medications will be returned to the pharmacy.
d. To avoid a recurrence of this violation, Residential Manager and Agency Nurse will conduct daily check and reported on a form indicating the name, doses, quantity of medication to be returned to the pharmacy. |
05/13/2016
| Implemented |
| 6400.151(a) | Staff #1's dated of hire was 05/15/2015 and there was no documentation to indicate a physical examination was completed before the hire date. (Repeat Violation 06.23.2015) | 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. | a. Administrator,
b. Moving forward, Halia will utilize an employment requirement checklist to verify potential employee¿s equalization before hire.
c. The Administrative assistant will ensure to review all documents thoroughly and submit them to the Administrator for final approval. If any applicant is found not meeting the requirement, such applicant is disqualified from being employment with Halia.
d. To further prevent a repeat of this violation, Halia will change and implement quality control concerning her employment methods. |
05/16/2016
| Implemented |
| 6400.161(b) | Motrin IB 200mg was found unlocked in a kitchen 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 all 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.[The Program Director will conduct monthly inspections of the home to ensure that all medications are locked at all times, starting immediately. SW 2.3.17] |
05/13/2016
| Implemented |
| 6400.164(c) | Individual # 1 self-medicates and a list of prescribed medication, the dosage and the prescribing physician was not in the home. | A list of prescription medications, the prescribed dosage and the name of the prescribing physician shall be kept for each individual who self-administers medication. | a. Residential manager, Administrator, Agency nurse
b. Halia¿s management immediately addressed missing medication. Individual#3 was taken to his PCP, and he was reordered Norvac 5mg and Synthyroid 50 mcg and the medications. issue of securely disposing of discontinued medications.
c. Halia has established a policy that addresses medication disposal process. All staff will receive ongoing training on how to ensure safe methods of disposal or destroying of medication. Halia¿s policy states that all discontinued and expired medications will be returned to the pharmacy.
d. To avoid a recurrence of this violation, Residential Manager and Agency Nurse will conduct daily check and reported on a form indicating the name, doses, quantity of medication to be returned to the pharmacy. [The Program director will conduct a training for all staff to understand the importance of documenting medication in the MAR for those Individuals that self-administer medications and will review the MAR's monthly to ensure that this documentation is maintained, starting immediately. SW 2.3.17] |
05/13/2016
| Implemented |
| 6400.168(a) | Staff # 6 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. CEO, Administrator, Residential Manager, Program Specialist
b. Staff will complete DMA annual practicum by 4/30/2016
c. Halia has developed a tracking tool to ensure that all staff are current/up-to-date with the Department's Medication Administration annual and quarterly practicum.
d. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs to maintain uniformity with licensing regulations. In addition, the office will send out training notice to staff so that staff would complete all required trainings. The administrative assistance will update training log, and update the staff employment folder.[Staff #6 will not administer medications until the training has been completed as required, within 10 days of receipt of this plan of correction. SW 2.3.17] |
05/13/2016
| Implemented |
| 6400.168(d) | Staff # 2 administered medications in November 2015, December 2015, and January 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 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 10/08/2014.
Staff # 4 administered medications in 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 11/13/2013.
Staff # 5 administered medications in November 2015 and January 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.
| A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | a. CEO, Administrator, Residential Manager, Program Specialist
b. Staff will complete DMA annual practicum by 4/30/2016
c. Halia has developed a tracking tool to ensure that all staff are current/up-to-date with the Department's Medication Administration annual and quarterly practicum.
d. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs to maintain uniformity with licensing regulations. In addition, the office will send out training notice to staff so that staff would complete all required trainings. The administrative assistance will update training log, and update the staff employment folder. [The Program Director will conduct bi-annual reviews of all medication administration training to ensure that all staff who administer medications are current, starting immediately. SW 2.3.17] |
05/13/2016
| Implemented |
| 6400.213(1)(i) | Individual # 1's record did not document their social security number, identifying marks, the individual¿s primary language used and a current dated photograph.
| Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | a. Program Specialist, and Administrator
b. The program specialist is currently updating the individual#1 program book to reflect progress on goals, that individual sign written consent for release of information, compete and update factsheet/face sheet, photograph to include all identifying information associated with the individual.
c. Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, lifetime Medical, etc.) current, and has taken the following steps to ensure that the program specialist review ISP, update expected outcomes/information as agreed upon in the individual¿s ISP.
d. Moving forward, the program specialist will ensure to update records and maintain an updated program book for each individual Halia served. The program specialist will submit to the management/administrator a monthly report of all quarterlies, updated ISP, assessments, etc. for final review. The Administrator will conduct weekly monitoring of the homes; individual¿s program books to maintain consistency. The program specialist will receive on-going trainings in his responsibilities in order to avoid a repeat of this non-compliance item. |
05/13/2015
| Implemented |
| 6400.217 | Individual #1's record did not include a written consent for release of information | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| a) Program Specialist, and Administrator
b) The program specialist is currently updating the individual#1 program book to reflect progress on goals, that individual sign written consent for release of information, compete and update factsheet/face sheet, photograph to include all identifying information associated with the individual.
c) Halia Home Care recognizes the importance of keeping the individual¿s documentation (e.g.: ISP, Quarterly reviews, Annual Assessment, lifetime Medical, etc.) current, and has taken the following steps to ensure that the program specialist review ISP, update expected outcomes/information as agreed upon in the individual¿s ISP.
d) Moving forward, the program specialist will ensure to update records and maintain an updated program book for each individual Halia served. The program specialist will submit to the management/administrator a monthly report of all quarterlies, updated ISP, assessments, etc. for final review. The Administrator will conduct weekly monitoring of the homes; individual¿s program books to maintain consistency. The program specialist will receive on-going trainings in his responsibilities in order to avoid a repeat of this non-compliance item.[The Program Director will conduct bi-annual audits of all Individuals records to ensure all of the elements of this regulation are documented in the record, starting immediately. SW 2.3.17] |
05/13/2016
| Implemented |
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