| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | REPEAT VIOLATIONS FROM 12/10/19: The self-assessment for this home is dated 8/3/20, which is outside of the required time frame. The self-assessment is also incomplete. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A self-assessment is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/finidings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. |
03/05/2021
| Implemented |
| 6400.103 | There are no written emergency evacuation procedures for the home. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| "Ensure a calm transition and the safety of people in care in an emergency situation Plans used in the past were found to be inadequate The current evacuation plan did not have a current address for the evacuation location with did not identify the staff responsibilites, means of transportation, and there was no explanation of the provision of services at the evacuation site. Directors reviewed the regulation and developed a template for a new evauation form that will be used in each residential location and for each resident. The Program Managers will complete the new form ensuring it is tailored to the unique needs of the residents they support. The Operational Associate Director responsible for the program will monitor that the form is completed corectly.
1) By 2/15/2021, the Directors will train each ADOS. 2) By 2/21/2021, each PM will be trained on how to create the plan and how to train thier staff on the plan. 3) Each Program Manager is responsible to complete the plan by 2/28/2021.
Training logs will be maintained to indicate the completion of the training. 1. The Directors of residential will develop a checklist that encompasses the required docuentation for a new admission. An element of the checklist will be to ensure that evacuation plans are completed. 2. The checklist will be used by each PM at the time a person is admitted in the residence. 3. The ADOS will be responsible to reveiew the checklist for completness.4. The completion of the checklist will also be monitored by the Director of Services and reported. " |
03/05/2021
| Implemented |
| 6400.112(a) | There were no fire drills conducted in the following months: 7/2020 and 8/2020. | An unannounced fire drill shall be held at least once a month. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. There was no documentation that the fire drills were conducted Documentation was not adequately maintained Fire Drills are now input and montiored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisiors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.144 | Individual #1 was a no-show for her blood draw to be completed on 6/22/20. There is no indication why she missed this appointment. | 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.
| Ensuring health services are received protects the health and safety of the people we support by making sure they receive appropriate healthcare services. The person supported scheduled the appointment and did not inform the staff. The appointment was missed because staff were unaware the person supported made the appointment. The Program Manager will collaborate with the person supported to ensure they are aware of appointments that are scheduled by the person in supports. The Directors of Residential will monitor the completion of this task during monthly supervisions with the Clinical Directors. |
03/19/2021
| Not Implemented |
| 6400.181(a) | Individual #1's date of admission is 12/16/19. Her initial assessment was not completed until 2/20/2020. | 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. | The initial assessment indicates functional strengths and needs, preferences and current levels of performance in areas such as communication and the levels of assistance needed. The Clinical Associate Director did not remember to complete the assessment on time. The initial assessment was completed on 2/20/2020. The Associate Directors will use the Outlook calendar app to enter due dates to ensure the timely completion of assessments. The Directors of Residential will review the as needed completion of this task during monthly supervisions. |
03/19/2021
| Not Implemented |
| 6400.32(r) | Individuals #1, #2, and #3 do not have locks on their bedroom doors and were not asked if they wanted locks. | An individual has the right to lock the individual's bedroom door. | Individuals have the right to have locks on their bedroom doors to protect their belongings. Individuals were not offered the opportunity to have locks placed on their bedroom doors. The choice to have a lock on a bedroom door was not discussed during team meetings. The residential provider will contact the individual's team to schedule a meeting to discuss the person's choice for a lock on the bedroom door. If the person wants a lock, the residential provider will ensure a lock is installed. The meetings will take place by 4/30/2021 and be scheduled by the Clinical ADOS before March 10 During the annual ISP meeting, or when the person requests, the residential provider will ensure the subject of securing the bedroom is discussed. The Directors of Residential will monitor the completion of this task during monthly supervisions with the residential Clinical and Operational Associate Directors. |
03/15/2021
| Implemented |
| 6400.165(c) | Individual #1's prescription for potassium was discontinued on 6/24/20. On the following dates, the medication was signed as administered to individual: 6/25/20, 7/1/20, 7/13/20, 7/27/20, and 8/23/20. | A prescription medication shall be administered as prescribed. | Providing a discontinued medication can be dangerous to the recipient and depending on the medication and other changes made to the regimen may lead to health complications The paper records did not allow for the proper paperwork to always be as up-to date as the orders provided by the physicians The violation occurred because the discontinuation of the medication order was not properly noted by the staff member the current methodology and the use of an electronic Medication Administration Record allows for real time changes and discontinuations to take place immediately. In addition only Program Managers and ADOS personnel receive, add and delete meds. The advent of the eMAR within the organization, allows for immediate discontinuation of medications and visual cues that don't allow someone to incorrectly continue to deliver medications without permissions. When there is a medication error, an incident report will be entered into the AWARDS system by the Program Manager and the EIM entry will be done by the LPN or RN in the Quality Department. |
03/12/2021
| Not Implemented |
| 6400.166(a)(2) | Individual #1's Medication Administration Record does not include the name of the prescriber for the following medications: Amlodipine, Paricalcitol, Potassium ER, Acetominophen. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The prescriber is important to know so that if questions about the medications, dosage or reactions can be imperative to the health of the persons supported by TLC The name of the prescriber is not included in the MAR for this individual The Program Manager did not review the labels on the medication after delivery. And the medication administration certified staff did not complete the 6 rights of medication administration, which includes ensuring the right documentation. There was a lack of supervision and follow through. The current Program Manager will routinely review the labels on medication after delivery. |
03/12/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record does not include the diagnosis or purpose for the following medications: Amlodipine, Folic Acid, Levetiracetam, Oxcarbazepine, Paricalcitol, Potassium ER, Vitamin B12, Warfarin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Knowing the diagnosis and purpose are important because the same medications could be used to treat a variety of different conditions. The Program Manager did not review the labels on the medication after delivery. The change in leadership and turnover in staff resulted in an oversight of this requirement. The current Program Manager will routinely review the labels on medication after delivery. The staff trained in medication administration will complete a weekly audit of medications and labels. The checklist will then be submitted to the Program Manager and the Program Manager will review the checklist. The checklist will be submitted to the Associate Director who will review and submit to the Directors of Residential. |
03/12/2021
| Not Implemented |