| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual # 1's financial records document a purchase of $24.14 on 09/06/2016 for three chicken dinner and a purchase of $28.49 on 08/30/2016 for three meals. | (2) Disbursements made to or for the individual.
| Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.31(b) | Individual # 1's most recent signed individual rights statement was dated 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. | Oversight responsibility: Program Specialist and Administrator. The program specialist corrected and updated individual rights statement, the individual's rights statement is current. Moving forward, the Administrator will supervise the PS to ensure that she complete and update all information in all individuals program book according to the 6400 regulations. (All program specialists will be retrained in their job duties within 30 days receipt of this plan. The executive director or designee will conduct a quarterly audit of individual records to begin within 30 days of receipt of this plan to identify any individual records out of compliance. If records are found to individual rights statements, the record will be corrected. The review is to be completed until all records have been reviewed and are in compliance with the regulation DS 02.15.17) |
12/15/2016
| Implemented |
| 6400.66 | There was no light in the living room.
There was one lamp in Individual # 1's and Individual # 2's bedroom which did not provide adequate lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| CEO, Financial Office, Residential manager, and Administrator has purchased, repaired and/or replaced lights in living room and bedroom areas: 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. |
12/15/2016
| Implemented |
| 6400.68(b) | The water temperature in the bathroom was measured at 131.9 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Oversight responsibility: Residential manager and Administrator. The residential manager does weekly checks on hot water temperatures and ensure that hot water temperature remains below 120F. Halia utilizes a thermostat and hot water check sheet to maintain hot water temperature level per 6400 regulations. The issues was resolved on 12/15/2016 |
12/15/2016
| Implemented |
| 6400.141(c)(9) | Individual # 1 did not have a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.142(a) | Individual # 1's most recent dental examination was completed on 06/02/2015. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.144 | Individual # 1 is prescribed Cleocin 1% lotion PRN and Perocet 325mg PRN and these medications were not in the home. | 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.
| Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
05/15/2016
| Not Implemented |
| 6400.163(c) | Individual # 1 's three month psychiatric review dated 05/18/2016 was blank. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Oversight responsibility: Program Specialist, staff, residential manager and Administrator. Individual#1 completed his psychotropic medication review (90-day review) on 11/16/2016, but the omission was acknowledged by the physician and the necessary corrections were completed on 12/6/2016. Moving forward, staff accompanying individual#1 will be more mindful and alert to having the entire form filled up before leaving the clinic. |
12/06/2016
| Not Implemented |
| 6400.181(a) | Individual # 1's most recent annual assessment was dated 05/23/2015 | 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. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.183(5) | Individual # 1 is prescribed psychotropic medication to treat a psychiatric diagnosis and there was no social, emotional and environmental plan or behavioral support plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Oversight responsibility: Program Specialist, staff, Residential manager and Administrator. Individual#1 completed his p |
12/15/2016
| Not Implemented |
| 6400.185(b) | The strategies used to track the progress towards Individual # 1's outcome of "healthy lifestyle" remained the same over two plan years. | The ISP shall be implemented as written. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the explores current strategies to promote individual#1's healthy lifestyle. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.186(a) | Individual # 1's most recent ISP review was dated 04/28/2016 through 06/28/2016 and the previous ISP review was dated 12/28/2015 through 03/28/2016. | 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. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.186(b) | Individual # 1's ISP reviews dated 12/28/2015 through 03/28/2016 and 04/28/16 through 06/28/2016 were not signed by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Oversight responsibility: Program Specialist and Administrator. The program specialist is now in continuous communication with all individuals, including individual #1's Supports Coordinator, and the error was noted. Moving forward, a discrepancy form will be sent to the SC requesting changes, updates and revisions as deem necessary to the individual ISP whenever there is an inconsistency found. |
12/15/2016
| Not Implemented |
| 6400.213(1)(i) | Individual # 1's record did not document hair color, eye color or identifying marks. | 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. | Oversight responsibility: Program Specialist and Administrator. The PS completed and updated individual#1's record indicating hair color and eye color and/or identifying marks. Moving forward, the PS reviews all individuals record on a monthly basis, while the Administrator monitor for accuracy. The updated was completed on 12/15/2016. |
12/15/2016
| Not Implemented |