| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(c) | The Chief Executive Officer (CEO) did not receive 24 hours of training within the previous annual training year. The training year is July 1. 2011 ¿ June 30 , 2012. | (c) The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | This violation resulted from the inability of the CEO to document the trainings and workshops attended over the past training year.
Going forward, all relevant trainings confirmed by the CEO will be documented and added to the training database. This database is being created and will be run monthly by HR. The HR Director will monitor this process to ensure that the CEO has 24 hours of training relevant to human services/administration annually. |
12/31/2012
| Implemented |
| 6400.46(d) | Employee A received 17 hours of training in the previous annual training year ( July 1, 2011 ¿ June 30, 2012. | (d) Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.
| This violation resulted from a HR error, whereby the training documentation for the employee in question was misplaced.
The system was in place whereby the training records were kept electronically; however the corresponding documentation could not be located in the employee chart.
A training was conducted for HR staff on 10/15/2012, and a training policy was also developed which will serve as a guide going forward for HR staff. |
10/15/2012
| Implemented |
| 6400.67(c)-2 | As a result of Lead Paint Testing completed on 4/12/2010, lead paint was found s on the basement stair railing; the levels were 2.7 mg/cm2. It was also determined that lead based paint dust was present on the basement floor . There has been no remediation to these findings. | If the testing shows lead content exceeding .06%, paint shall be completely stripped and recovered with lead free paint or securely encased with other lead free material. Documentation of the lead paint testing and results shall be kept. | This violation resulted from lack of documentation to show the remediation conducted as requested by the Lead inspectors on 04/12/2010.
On 10/26/12 remediation was conducted by ensuring all paint in the house had no flaking,as well the basement floor cleaned with high phosphate solution. A clearance inspection was conducted on 11/02/12 which confirmed that lead content in all subject area are below permissible levels. Hence, the property passed clearance inspection.
Going forward, all documentation of lead paint testing results as well as remediation actions will be kept electronically as well as on file. The Director of Operations will be responsible for this. |
11/02/2012
| Implemented |
| 6400.141(c)(4) | Individual #1 did not have vision or hearing screening completed in the past 12 months. This is a Repeated Non-Compliance (RNC). | (4) Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
| This violation resulted from an oversight by the program to follow through in ensuring that the individual had this required screening completed annually.
An appointment has been scheduled at the individual's PCP for 11/29/12 to have Vision and Hearing screening completed. In addition, an appointment is scheduled with a Vision specialist for 02/22/13.
All completed appointment forms will be submitted to the Assistant Residential Director, who will within 48 hrs from time of completion of appointment, review the returned forms for accuracy and schedule follow up appointments. A tracking spreadsheet will be used to monitor upcoming appointments and the Assistant Residential Director will be responsible for this. |
11/29/2012
| Implemented |
| 6400.142(a) | Indiviudal # 1's last dental examination was 3/17/11. | (a) 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.
| This violation resulted from an oversight by the program to follow through in ensuring that the individual had this required screening completed annually.
The Individual had his annual dental appointment completed on 10/10/12.
All completed appointment forms will be submitted to the Assistant Residential Director, who will within 48 hrs from time of completion of appointment, review the returned forms for accuracy and schedule follow up appointments. A tracking spreadsheet will be used to monitor upcoming appointments and the Assistant Residential Director will be responsible for this.
|
10/10/2012
| Implemented |
| 6400.142(f) | Individual # 1 did not have a dental hygiene plan. | (f) An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence.
| This violation resulted from an oversight by the program to follow through in ensuring that the individual had this required plan completed annually.
The Dental plan for this Individual was completed 10/10/12 by his Dentist.
All completed appointment forms will be submitted to the Assistant Residential Director, who will within 48 hrs from time of completion of appointment, review the returned forms for accuracy and schedule follow up appointments. A tracking spreadsheet will be used to monitor upcoming appointments and the Assistant Residential Director will be responsible for this.
|
10/10/2012
| Implemented |
| 6400.168(d) | Emplyee A's annual practicum was due on 7/29/2012; however, it was not completed until 10/4/2012. | (d) A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually.
| This violation resulted from a HR/ training process error whereby the Medication Administration trainer was keeping annual practicum records for himself and not forwarding to HR, hence there was no dual record system.
This violation has been corrected by a dual record system, whereby all Medication Administration and annual practicum documentation including dates of training for all staff is now kept in HR along with all employee training records. This information is added to staff annual training database which will keep track of all required trainings.
Going forward, practicum records will be included in the monthly training report hence due dates for practicum will be monitored eliminating the possibility of completing Practicum late. |
10/15/2012
| Implemented |
| 6400.181(e)(8) | Indvidual # 1's evaulation skills were not listed on the annual assessment. | (8) The individual's ability to evacuate in the event of a fire.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations.
A new assessment was completed 10/15/12, and team meeting held same day to review and sign off the new assessment.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director. |
10/28/2012
| Implemented |
| 6400.181(e)(13)(i) | There was no progress and growth listed in the individual's assessment . | (13) The individual's progress over the last 365 calendar days and current level in the following areas:
(i) Health.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations. A new assessment was completed 10/15/12 to include progress and current level in the areas of Health, and Motor and communication skills. Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director. |
10/15/2012
| Implemented |
| 6400.181(e)(13)(iii) | There was no progress and growth listed in the individual's assessment | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (iii) Activities of residential living.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (iv) Personal adjustment.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations.
A new assessment was completed 10/28/12 to include progress and current level in the areas of Activities of Residential living and Personal adjustment.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director.
|
10/28/2012
| Implemented |
| 6400.181(e)(13)(v) | There was no progress and growth listed in the individual's assessment. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (v) Socialization.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations.
A new assessment was completed 10/28/12 to include progress and current level in the areas of Socialization and Recreation.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director.
|
10/28/2012
| Implemented |
| 6400.181(e)(13)(vii) | There was no progress and growth listed in the individual's assessment. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (vii) Financial independence.
(13) The individual's progress over the last 365 calendar days and current level in the following areas: (viii) Managing personal property.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations.
A new assessment was completed 10/28/2012 to include progress and current level in the areas of financial independence managing personal property.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director.
|
10/28/2012
| Implemented |
| 6400.181(e)(13)(ix) | There was no progress and growth listed in the individual's assessment. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (ix) Community-integration.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim.
| This violation resulted due to an oversight by the Program Specialist in ensuring that the individual's assessment captured all relevant aspects as specified by 6400 regulations.
A new assessment was completed 10/28/2012 to include progress and current level in the area of Community integration and knowledge of water safety and ability to swim.
Going forward, the program specialist will ensure relevant sections of the an assessment as specified by 6400 regulations are captured in assessments. All completed assessments must be reviewed for content and accuracy by the Assistant Residential Director.
|
10/28/2012
| Implemented |
| 6400.181(f) | Individual's #1's assessment was completed 10 days after the Indivual Support Plan (ISP) meeting date. The ISP meeting was on 12/6/11. The assessment was date. 12/16/11. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| This violation resulted due to an oversight by the Program Specialist in complying with the 6400 regulation as it relates to time required for an assessment to be provided to the SC and plan team members before an ISP meeting.
A tracking sheet has been developed, and will be used by the Program specialist to track, complete and send assessments 30 days prior to the ISP meeting date. A new assessment was completed 10/15/2012 and has been provided to the SC and plan team members 30 days before the ISP meeting of 11/20/2012
The Assistant Residential Director will monitor this to ensure compliance. |
10/28/2012
| Implemented |
| 6400.183(5) | Individual #1's last Behavioral Support Plan was dated 7/8/11 | (5) 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.
| This violation resulted due to the inability of the program specialist to ensure that a current BSP existed in the individual's record.
Behavioral supports was recently approved by the SC in this individual's plan.The behavior specialist for this individual has been communicated to provide an updated BSP for this individual.
Going forward, the program specialist will ensure that there are current BSP for individuals who has medication prescribed to treat symptoms of a diagnosed psychiatric illness. An excel spreadsheet will be developed will be developed which will be used to track the expiration of such BSP's. |
11/30/2012
| Implemented |
| 6400.184(b) | There were only two team members were present at Individual #1's ISP meeting; the Supports Coordinator and the Behavioral Supports Specialist.
| (b) At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting.
| This violation resulted due to an oversight in complying with the regulations as it relates to the number of plan team members required at an ISP meeting.
Going forward, the Program Specialist must ensure that Casmir staff attends ISP meetings and that at least 3 plan team members must be present. This process has already been implemented for 2 individuals who has had their ISP meetings since date of inspection. |
11/07/2012
| Implemented |