| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Individuals in the facility are assessed to be unsafe around poisonous materials. Poisonous materials were located within the first aid kit in the first aid room, not locked or made inaccessible to individuals when they utilized the first aid room. The kit contained antiseptic wipes, liquids, and creams that contained labels to contact poison control center if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | This occurred due to the management thinking it was acceptable to have the poisonous materials locked via the first aid room door, however, they were educated on the importance of having them locked within the room as well. TLC immediately placed a locked cabinet into the First Aid room and placed all poisonous materials into this cabinet. |
11/21/2022
| Implemented |
| 2380.89(c) | The fire drill record for the 7/5/22 fire drill did not record the exit route used during the drill.
The following fire drill records did not include if the smoke detector used and all smoke detectors in the building were operable at the time of the fire drill: 7/5/22, 6/1/22, 5/9/22, and 2/1/22. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | This occurred due to the fire drills not being reviewed by managers. TLC day program management staff will audit all fire drill forms to ensure all fields are completed. All day program managers will be retrained on fire drill forms. There will be an audit performed monthly to ensure that forms are completed entirely. |
12/01/2022
| Implemented |
| 2380.89(g) | The fire drill record for the drill held on 2/1/22 did not indicate if the individual's met at the meeting place. This was missing from the record. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | This occurred due to the fire drills not being reviewed by managers. TLC day program management staff will audit all fire drill forms to ensure all fields are completed. All day program managers will be retrained on fire drill forms. There will be an audit performed monthly to ensure that forms are completed entirely. |
12/01/2022
| Implemented |
| 2380.91(a) | Individual #1 received training in general fire safety and the requirements of 2380.91(a) on 6/21/21 and not again until 10/11/22.
Individual #2 received training in general fire safety and the requirements of 2380.91(a) on 6/1/21 and not again until 10/11/22. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility. | TLC did not previously have a set date for fire safety training, however, this was changed in 2022. Audit was completed for fire safety training records of all individuals, and all individuals are currently up to date for fire safety training. |
11/23/2022
| Implemented |
| 2380.111(c)(4) | Individual #2's 5/5/22 physical examination record did not include an evaluation of their vision and hearing. The physical examination record indicated the vision and hearing screening could not be completed at the time of the physical examination. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | This occurred due to the current form not having clear instructions on completion. All annual physicals for day program individuals will be audited to ensure all fields have been completed during the exam. If there are missing components, staff will contact the physician and amendments will be made as necessary. |
12/15/2022
| Implemented |
| 2380.111(c)(10) | Individual #1's current, 8/16/22 physical examination record did not include information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This occurred due to the current form not having clear instructions on completion. All annual physicals for day program individuals will be audited to ensure all fields have been completed during the exam. If there are missing components, staff will contact the physician and amendments will be made as necessary. |
12/15/2022
| Implemented |
| 2380.113(a) | Staff person #1 was re-hired on 10/11/21. The only physical examination they had completed was on 1/6/2020, more than a year prior to their date of hire. Additionally, at the time of the 11/14/22 inspection, they did not have an additional physical examination completed within 2 years of their 1/6/2020 physical examination. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | This occurred due to the staff being a re-hire and several things were overlooked. HR is going to conduct an audit to ensure that all staff are up to date with their physicals. |
12/15/2022
| Implemented |
| 2380.173(1)(iv) | Individual #1's and #2's records didn't include their religious affiliation. Their identification sheets indicated they had "other" listed for their religious denomination but did not describe or list the denomination. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | This occurred due to lack of monitoring of the face sheet information, and lack of information upon admission. The Director of Operations is currently auditing all face sheets for all regulatory requirements. All face sheets with missing information or errors will be corrected by 12/15/2022. |
12/15/2022
| Implemented |
| 2380.174(b) | The most current copy of Individual #1's individual support plan was not kept at the facility in their record. The facility had record of the individual's individual support plan that was last updated on 4/1/22. However, the individual's plan has been updated 4 times since then, including two critical revision updates, an annual update, and a fiscal update. | The most current copies of record information required in § 2380.173(2)¿(11) shall be kept at the facility. | This occurred due to limited management staff and oversight. TLC is hiring a Director of Day Services to help with these responsibilities and ensure management oversights. All ISP plans have been updated as of 11/22/2022, and all plans are present at the facility. TLC's goal date for filing this position by 01/16/2022. |
11/22/2022
| Implemented |
| 2380.181(a) | REPEAT from 12/13/21 annual inspection: Individual #1 had an assessment completed on 8/31/2020 and not again until 12/7/2021, outside the annual time frame requirement.
Additionally, Individual #1's 8/31/2020 and 12/7/2021 assessments are exactly verbatim, therefore not assessing the individual's current needs or their progress or regression in skills related to the previous 365 days. At the time of the 11/14/2022 inspection, the individual's assessment has not been updated to include their current level skills and needs or any progress or regression since their 8/31/2020 assessment was completed.
Individual #2's 11/19/2020 assessment and the assessment created in 2021 are almost verbatim, therefore not assessing the individual's current needs or their progress or regression of skills related to the previous 365 days. At the time of the 11/14/22 inspection, the individual's assessment has not been updated to include current information. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | This occurred due to the lack of program management, there has since been a Director of Day Services position created to oversee the administrative and management tasks. The Program Specialist is completing new assessments for both individuals. The Day Program ADOS is auditing the Annual Assessments to ensure that each assessment is reflective upon any changes. The goal date for hiring the Director position is 01/16/2023. |
12/15/2022
| Implemented |
| 2380.181(d) | The program specialist did not sign and date Individual #2's 2021 assessment. | The program specialist shall sign and date the assessment. | The staff member who had completed the assessment was terminated, following termination, her work was not reviewed thoroughly. The program specialist is completing a new assessment which will include all of the regulatory requirements, and will sign and date the assessment when completed. All other annual assessments are being audited to ensure they are completed thoroughly, dated and signed by the program specialists. |
12/31/2022
| Implemented |
| 2380.181(e)(7) | REPEAT from 12/13/21 annual inspection: Individual #1's 2020 and 2021 current, and previous assessments did not include the individual's ability to move away from heat sources. | The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The staff member who had completed the assessment was terminated, following termination, her work was not reviewed thoroughly. The program specialist is completing a new assessment which will include all of the regulatory requirements, and will sign and date the assessment when completed. All other annual assessments are being audited to ensure they are completed thoroughly, dated and signed by the program specialists. |
12/31/2022
| Implemented |
| 2380.181(e)(10) | Individual #1's 2020 and 2021 current, and previous assessments did not include the individual's lifetime medical history. Individual #1 is prescribed medication for agitation and anxiety, mood disorder, and hypothyroidism. Their assessment does not include these diagnoses.
Individual #2's 2021 assessment didn't include their lifetime medical history. Per the individual's previous 2020 assessment, they had cancer in 2019 and surgeries in 2020 to remove cancer spots and tumors, along with radiation, and previous childhood surgeries. | The assessment must include the following information: A lifetime medical history. | The staff member who had completed the assessment was terminated, following termination, her work was not reviewed thoroughly. The program specialist is completing a new assessment which will include all of the regulatory requirements, and will sign and date the assessment when completed. All other annual assessments are being audited to ensure they are completed thoroughly, dated and signed by the program specialists. |
12/31/2022
| Implemented |
| 2380.21(u) | Individual #1 was informed of their rights on 6/21/21 and not again until 7/19/22, outside the annual time frame requirement. Additionally, the rights reviewed with Individual #1 on 6/21/21 and 7/19/22 didn't include a review of their rights defined in 2380.21(a)-(g), and 2380.21(r)-(t).
Individual #1's individual support plan states their mother and father are their legal guardians. The individual's legal guardians were never informed of the individual's rights and the process to report a rights violation.
Individual #2 was informed of their rights on 6/1/21 and not again until 11/14/22, outside the annual time frame requirement. Additionally, the rights reviewed with Individual #2 on 6/1/21 and 11/14/22 didn't include a review of their rights defined in 2380.21(a)-(g), and 2380.21(r)-(t).
Individual #2's record states they have a family member appointed as their power of attorney. The individual's power of attorney was never informed of the individual's rights and the process to report a rights violation. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | This occurred due to TLC Day Program management staff utilizing the incorrect Individual Rights form. A new form has been created that includes all components of the 2380.21 regulations. Day Program ADOS is sending a letter to the families of individuals at Day Program by November 25, 2022, to send TLC updated POA and Guardianship paperwork. Individual Rights will be reviewed with all individuals the week of 12/15/22. Copies of the Individual Rights will be sent to all families and guardians the week of 12/15/2022. |
12/15/2022
| Implemented |
| 2380.38(b)(5) | Staff person #2 was hired on 9/6/22. The facility did not produce records that Staff person #2 received orientation training specific to all individual's plans, protocols and needs prior to working with individuals. | The orientation must encompass the following areas: Job-related knowledge and skills. | This occurred due to TLC not documenting clearly that the specific plans and protocols were part of the orientation. TLC has developed an additional training sheet that is specific for individual's plans, protocols, and needs which all new staff will have to sign as a part of their job related knowledge and skills checklist. TLC Day Program management is completing an audit to ensure all staff are trained on the current plans. |
11/23/2022
| Implemented |
| 2380.39(c)(5) | Staff person #1 was hired on 10/11/21. There are no records that within their first year of employment they received annual training in the use of behavior support, behaviors plans, and individual-specific behavior plans for individuals at the facility they support. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | This occurred due to TLC not having this requirement as a part of the orientation process. As of April 2022, this has been added to orientation. All day program staff will be trained on behavior supports, behavior plans, and individual specific behavior plans for individuals in day program during their in-service meeting which occurs on January 16, 2023. |
12/29/2023
| Implemented |
| 2380.39(c)(6) | Staff person #1 was hired on 10/11/21. There are records that within their first year of employment they received annual training in individual-specific plans for only 12 of the 17 individuals at the facility they support.
Additionally, Individual #1's individual plan states there are additional charting (symptoms charts, hygiene plan, scripting plan, communication plan) for staff to implement and that all staff are trained on these protocols. Records of this was not provided for Staff Persons #1 and #2. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | This occurred due to the lack of documentation, and lack of management staff and oversight. TLC will be hiring a Director of Day Services to assist with these management responsibilities. All day program staff will be trained on plans for individuals in day program during their in-service meeting which occurs on January 16, 2023. |
12/29/2023
| Implemented |
| 2380.123(a) | Individual #3's Diazepam medication at the facility was stored in a bottle with a pharmaceutical label that stated medication was dispensed in the bottle from the pharmacy on 9/10/22 and 90 pills were in the container. At the time of the 11/15/22 inspection, only 5 pills were in the medication bottle. Per facility staff, Individual #3's mother refills the medication bottle with 5 pills per week and sends the bottle into the program. The facility is aware the individual's mother is removing medication from the original container and refilling the container with 5 pills per week. The facility has never confirmed with the pharmacy that the 5 pills brought to the facility each week in the medication bottle is Diazepam that was dispensed from the pharmacy on 9/10/22. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by pharmacy. | This occurred due to the individual residing with family and prescription not being monitored by residential staff. Per previous management, staff were not previously advised to send individuals home if there are issues with their prescription medications, which is now part of the day program medication protocol. Letters will be sent out before 12/15/2022. All medications will be audited to ensure that they are in their originally labeled containers and all families will be receiving letters explaining the necessity for prescription and non-prescription medications to be kept in their original labeled containers. Audit will be completed by 12/15/2022. |
12/15/2022
| Implemented |
| 2380.125(c) | Individual #4 is prescribed Risperidone .5mg at noon daily. Staff person #3 didn't administer the medication until 3:11pm on 10/11/22. The individual's medication administration records did not document any information about the late administration only being a documentation error. | A prescription medication shall be administered as prescribed. | This occurred due to the staff documenting incorrectly and not choosing Late Documentation, or writing a note to correlate, making it look like it was administered late. This was a documentation error that was caught and retrained on, however, there was a lack of documentation. October and November Day program MARs will be audited to ensure that documentation was completed accurately, and incident reports were made as necessary. This audit will be completed by 12/31/2022. |
12/31/2022
| Implemented |
| 2380.126(a)(2) | Individual #3's medication administration records did not include the name of the prescriber for their Diazepam. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | This occurred due to the management staff not updating or monitoring the Day Program MARs. The Program Manager is checking all medication records and comparing the records to ensure that all fields are completed on the MAR and will update all as necessary. |
12/15/2022
| Implemented |
| 2380.126(a)(6) | Individual #3's medication administration records (mars) did not include the dosage form their Diazepam medication is to be administered. The medication is dispensed from the pharmacy in pill form. However, the individual requires all medication to be crushed. The mars did not include the order to crush the medication and the exact substance to mix the medication in prior to administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | This occurred due to the management staff not updating or monitoring the Day Program MARs. The Program Manager is checking all medication records and comparing the records to ensure that all fields are completed on the MAR and will update all as necessary. |
12/15/2022
| Implemented |
| 2380.126(b) | Two staff with the same initials recorded their names on Individual #4's medication records. There was no distinction on the individual's mars to differentiate which staff administered the medication.
The staff that administered Risperidone to Individual #4 on 10/13/22 did not record their name and initials and document the administration until 10/18/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | There is an audit being completed to ensure that there are not duplicate staff initial's in the MAR system. Certified medication administration trainers will ensure that the staff's middle initials are added if there are duplicates. |
12/31/2022
| Implemented |
| 2380.127(b) | Individual #3's Diazepam ordered for their anxiety, wasn't administered on 11/15/22 at noon. Staff reported the medication error in the Department's incident management system. Follow-up action documented on the incident report indicated the individual's mother was going to send extra medication for the facility in the event Individual #3 doesn't have the medication available at the facility again. As of the 11/16/22 onsite inspection, extra medication, outside their allotted pills for the week, was not present at the facility. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | This occurred due to TLC not following up with the individual's mother to ensure that there was extra medication sent in to the facility. TLC reached out to request the mother to send in additional medication. TLC will follow up with this again by 11/28/2022 to ensure medication is available at the facility. |
11/28/2022
| Implemented |
| 2380.183(b) | The record of those in attendance for Individual #2's 1/12/22 annual individual plan meeting did not include Individual #2. There are no records if the individual chose not to attend, if their power of attorney did not want them to attend, or if they attended any portions or their entire individual plan meeting. | At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised. | The individual was present at the virtual meeting, the individual's name was not written on the sheet. The Associate Director of Services is reviewing all attendance sheets to ensure they are completed by 12/31/2022. If an individual was not present for the meeting, the Associate Director of Services will confirm there is documentation as to why, and will follow up with the SC as necessary. |
12/31/2022
| Implemented |
| 2380.185(5) | Individual #1's individual support plan states they require a 1:1 staff to individual ratio when at the facility. The individual's assessments confirm this by stating the need for the 1:1 staff to individual ratio is due to potential harm to individual and other's if not presented with 1:1 staffing ratio. The individual's individual support plan also states the individual can have up to 15 minutes of unsupervised time at the facility. These two different levels of supervision are drastically different in their requirements and could result in physical harm to oneself or others if left unsupervised.
Additionally, Individual #1 is prescribed Lorazepam .5mg tablet, take 1 tablet by mouth three times daily as needed for anxiety or agitation, per their primary physician. The individual's plans do not include this medication and it's current order, nor is the medication available to the individual at the facility should they need it. The individual's plans do not address how the facility will obtain the medication if needed, or the plan to implement if the individual requires the medication and it's not at the facility.
According to the individual's behavior tracking, staff have documented physical aggression, verbal aggression, self-injurious behaviors, elopement, hallucinations, choking/gagging herself, finger down her throat, eating uncooked food/nonfood items, cursing, picking at skin. These behaviors are not included in the individual's social, emotional, environmental needs (SEEN) plan or in the individual's plan. There are no plans for how to mitigate the behaviors to prevent harm to oneself or others. There isn't tracking of the specific behaviors other than the type of behavior and a date and time it was entered on the behavior tracking chart. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | TLC is reviewing supervision care needs and will request an update to the ISP. TLC is reaching out to the prescribing physician to gain clarity on when the individual is to be receiving the Lorazepam and will develop a protocol reflecting the physician's recommendations. An ISP change will be requested to reflect this information. The individual's SEEN plan is being reviewed and will be updated to reflect changes in behaviors, and strategies for staff to help mitigate these behaviors. |
12/15/2022
| Implemented |
| 2380.183(c) | Individual #1 had an annual individual support plan meeting on 10/19/2022. The facility did not keep record of those in attendance for the meeting. | The list of persons who participated in the individual plan meeting shall be kept. | TLC was unable to obtain the attendance sheet for this ISP meeting after reaching out to the SC. The Associate Director of Services is auditing all other individual records to ensure that the attendance sheets are present, and will reach out to SC if there are any missing attendance records. |
12/31/2022
| Implemented |