| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeat from inspection dated 1/11/21) No Self-Assessment was completed for this home. | 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.
| This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly. Quality department will monitor for completion.Staff will be trained on how to complete the Self-Assessment form thoroughly on 2/22/22. |
02/22/2022
| Implemented |
| 6400.22(d)(1) | The Snap Benefit log that staff documents for Individual #1 was missing the following transactions: 8/1/21-$95.45 and 9/14/21-$92.01. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | This occurred due to the staff not turning in necessary receipts, potentially due to lack of training or knowledge. TLC has designated the Assistant Program Managers to complete the money book and the Program Managers to review before submitting to fiscal as opposed to having DSPs submitting them. TLC will retrain all staff on 6400.22 requirements including Money Books and requirements for receipt keeping by 2/22/22. |
02/22/2022
| Not Implemented |
| 6400.22(e)(3) | Individual #1's Snap Benefit log was missing the following receipts: 8/1/21-$95.45 and 9/14/21-92.01. | 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. | This occurred due to the staff not turning in necessary receipts, potentially due to lack of training or knowledge. TLC has designated the Assistant Program Managers to complete the money book and the Program Managers to review before submitting to fiscal as opposed to having DSPs submitting them. TLC will retrain all staff on 6400.22 requirements including Money Books and requirements for receipt keeping. |
02/22/2022
| Implemented |
| 6400.67(b) | There was a golf-ball sized amount of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The lint was immediately removed. This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022. |
02/22/2022
| Implemented |
| 6400.103 | (Repeat from Inspection dated 1/11/21)-There was no written emergency evacuation plan for Individual #1. The written evacuation plan was a medical emergency plan. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| This occurred due to there being a standard form in AWARDS for staff to complete that did not meet regulations. Residential staff will be rewriting all emergency medical plans after creating a new template which will be based off the 6400 regulations. |
02/28/2022
| Implemented |
| 6400.112(e) | (Repeat from Inspection dated 1/11/21)-A sleep drill was held on 1/8/21 and not again until 10/10/21; outside of the bi-annual time frame. | A fire drill shall be held during sleeping hours at least every 6 months. | This occurred due to TLC currently has a form on SharePoint that staff complete following a fire drill. Quality department will utilize the Fire Drill Log form which was updated on 1/20/2022 to determine which homes have not completed fire drills. Quality department will send email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained no later then 2/22/22. |
03/01/2022
| Not Implemented |
| 6400.141(b) | (Repeat Violation from 1/11/21, 5/10/21, and 10/12/21) The physical completed 7/23/21 is not signed or dated by the PCP. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | This occurred due to staff not being trained on medical appointments, required documentation, retraining/ educating individuals when refusing and documenting, nor were medical appointments, forms or orders being monitored following appointments. Staff will be retrained on medical appointments and requirements including printing medical appointment form prior to appointment, taking the form along, ensuring the form is completed and signed my licensed medical professional (not CRNP or nurse). This will be completed by 2/16/22.
QD is currently going through records to determine dates of all individual's annual physicals and will contact appropriate management to schedule the appointment (PS, PM). This will be completed by 2/16/22. Physicals will be scheduled in advance to ensure completion. |
02/28/2022
| Implemented |
| 6400.143(a) | (Repeat from 1/11/21 and 10/12/21) Individual #1 is to exercise 30 minutes a day. From 10/7/21 to the present the individual refused to participate 64 times. The refusals are documented. There is no documentation that the Individual was trained on the importance of following doctor's recommendations. From January 2021 to 10/7/21, this was not tracked. From 10/7/21 to the present, there were 9 times the physical activity was not logged. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | All direct care staff will be retrained on regulation 6400.143(a) which states, "If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record." Training record will be signed by all direct care workers by 2/22/22. |
02/28/2022
| Not Implemented |
| 6400.144 | Individual #1 has a BM protocol that the individual is to receive Miralax if the individual has no BM for three days. The individual did not have a BM from 9/27/21 to 9/29/21, from 11/3/21 to 11/5/21, from 11/20/21 to 11/22/21, and from 12/17/21 to 12/19/21. No Miralax was administered. | 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.
| Staff will be trained on the importance of documenting and tracking bowel movements whether seen, unseen or reported by individual by 2/22/22. |
02/28/2022
| Not Implemented |
| 6400.145(3) | (Repeat from inspection dated 1/11/21) The emergency medical plan developed for Individual #1 does not address emergency staffing. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | This occurred due to there being a standard form in AWARDS for staff to complete that did not meet regulations. Residential staff will be rewriting all emergency medical plans after creating a new template which will be based off the 6400 regulations. |
02/28/2022
| Implemented |
| 6400.181(a) | (Repeat from 1/11/21, 5/10/21, and 10/12/21)-Individual #1 had an annual assessment completed on 9/16/20 and not again since; outside of the annual time frame. | 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. | This occurred because there has been a significant turnaround in Program Specialists as well as a lack of training/ supervision and monitoring. Program Specialists will be retrained on annual assessment requirements per the 6400 regulations including the requirements for which documents need to be uploaded to Individual's File Cabinet along with the ISP (including the attendance record, and if individual was unable to attend, a substantiation). Intermittently, quality department contacted the Program Specialist of each individual who needs an updated assessment as well as the Director of Residential Services and provided due date of required assessments to be completed by 02/28/2022. |
02/28/2022
| Not Implemented |
| 6400.211(b)(3) | Individual #1's record does not indicate who to contact for medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Program Specialists will update the current face sheet with necessary information immediately. |
02/28/2022
| Implemented |
| 6400.18(c) | Individual #1 had medication errors on the following dates: 6/17/21, 7/21/21, 8/6/21, 10/2/21, and 10/22/21. Family was not notified of any of the medication errors. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | This has occurred due to the lack of understanding of the medication error regulation. TLC has updated the AWARDS incident form immediately (01/04/2022) to eliminate the drop-down option, "Per regulations family notification is not made for medication errors." It has been added in the incident management training that family notification must occur for medication errors. We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, Individual Funds and Property and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). |
02/22/2022
| Not Implemented |
| 6400.165(c) | (Repeat from 1/11/21, 4/26/21, 5/10/21, and 10/12/21) Individual #1 is to receive Divalproex 500 mg twice a day, at 8am and 8pm. On 3/16/21, Individual #1 received two doses of Divalproex 500mg at 8pm. | A prescription medication shall be administered as prescribed. | This occurred due to a lack of training and monitoring regarding documentation. TLC has recognized the need for continued training and has added the nurses to complete quality monitors for medication and medication management. TLC has now hired a full-time LPN, RN and an additional Training Specialist. The nurses will be reviewing physician orders and updating CARASOLVA/ AWARDS as necessary to ensure that all medications are updated, correct, and all components are completed. The new Training Specialist will focus on the Med Training and Med Observations and complete retraining as necessary as well as updated the AWARDS forms to ensure that all medication errors are addressed appropriately. Staff will be retrained to on proper documentation, medication management, the 5 rights of medication, quarterly medication reviews, discontinuation and disposal. Education regarding the medication error and reporting will occur during the ALL Staff Meeting on February 22, 2022. Training specialist will begin February 28th. |
02/28/2022
| Not Implemented |
| 6400.165(g) | (Repeat from 1/11/21 and 5/10/21) Individual #1 had a Psychiatric Medication Review completed on 1/25/21, 6/28/21, and 12/6/21. Med Reviews were not completed quarterly as regulations require. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Program Specialists will be retrained on quarterly medication reviews and the requirements by 2/16/22. |
02/28/2022
| Implemented |
| 6400.166(b) | (Repeat from 6/30/21 and 10/12/21) Individual #1 received Sodium Chloride at 4pm on 11/11/21. It was not logged immediately. It was logged the following evening. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This occurred due to a lack of training and monitoring regarding documentation. TLC has recognized the need for continued training and has added the nurses to complete quality monitors for medication and medication management. TLC has now hired a full-time LPN, RN and an additional Training Specialist. The nurses will be reviewing physician orders and updating CARASOLVA/ AWARDS as necessary to ensure that all medications are updated, correct, and all components are completed. The new Training Specialist will focus on the Med Training and Med Observations and complete retraining as necessary as well as updated the AWARDS forms to ensure that all medication errors are addressed appropriately. Staff will be retrained to on proper documentation, medication management, the 5 rights of medication, quarterly medication reviews, discontinuation and disposal. Education regarding the medication error and reporting will occur during the ALL Staff Meeting on February 22, 2022. Training specialist will begin February 28th. |
02/28/2022
| Implemented |
| 6400.167(c) | (Repeat from inspection dated 10/12/21) Individual #1 is to receive Divalproex 500 mg twice a day, at 8am and 8pm. On 3/16/21, Individual #1 received two doses of Divalproex 500mg at 8pm. This medication error was not reported in EIM. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | This occurred due to a lack of training and monitoring regarding documentation. TLC has recognized the need for continued training and has added the nurses to complete quality monitors for medication and medication management. TLC has now hired a full-time LPN, RN and an additional Training Specialist. The nurses will be reviewing physician orders and updating CARASOLVA/ AWARDS as necessary to ensure that all medications are updated, correct, and all components are completed. The new Training Specialist will focus on the Med Training and Med Observations and complete retraining as necessary as well as updated the AWARDS forms to ensure that all medication errors are addressed appropriately. Staff will be retrained to on proper documentation, medication management, the 5 rights of medication, quarterly medication reviews, discontinuation and disposal. Education regarding the medication error and reporting will occur during the ALL Staff Meeting on February 22, 2022. Training specialist will begin February 28th. |
02/28/2022
| Not Implemented |
| 6400.181(f) | (Repeat from 1/11/21, 5/10/21, and 10/12/21)-Individual #1 had an annual assessment completed on 9/16/20 and not again since; outside of the annual time frame. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This occurred because there has been a significant turnaround in Program Specialists as well as a lack of training/ supervision and monitoring. Program Specialists will be retrained on annual assessment requirements per the 6400 regulations including the requirements for which documents need to be uploaded to Individual's File Cabinet along with the ISP (including the attendance record, and if individual was unable to attend, a substantiation). Intermittently, quality department contacted the Program Specialist of each individual who needs an updated assessment as well as the Director of Residential Services and provided due date of required assessments to be completed by 02/28/2022. |
02/28/2022
| Implemented |