| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeat from inspection dated 1/11/21) The self-assessment that was completed was not dated. There is no way to verify the self-assessment was completed within the correct timeframe. | 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 by 2/22/22 |
02/22/2022
| Implemented |
| 6400.15(c) | The self-assessment completed identified the following violations: 167a1-167a8, 167b, 167c, and 167d1-d2. No written plan of correction was completed. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| 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 by 2/22/22 |
02/22/2022
| Implemented |
| 6400.64(a) | During this inspection, Individual #2's shower chair had a golf ball sized amount of fecal matter on the top of the chair. | Clean and sanitary conditions shall be maintained in the home. | Shower chair was cleaned. 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.
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, 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
| Implemented |
| 6400.112(h) | During the 4/13/21 fire drill, the individuals met "across the street" and not at the designated meeting spot, the "mailbox at the end of the driveway". | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | TLC has designated only one meeting place for all homes, and the training has been updated. All staff will be retrained by 02/22/2022. 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
| Implemented |
| 6400.141(c)(3) | Individual #1's most current physical completed on 1/25/21 did not include information related to the following immunizations: Tetanus/Diphtheria. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 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 |
| 6400.141(c)(4) | (Repeat from inspection dated 5/10/21): Individual #1's most current physical completed on 1/25/21 did not include a vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 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 |
| 6400.141(c)(10) | (Repeat from inspection dated 5/10/21): Individual #1's most current physical completed on 1/25/21 did not include if individual #1 is free from communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 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 |
| 6400.141(c)(12) | Individual #1's most current physical completed on 1/25/21 did not include if individual #1 has physical limitations. | The physical examination shall include: Physical limitations of the individual. | 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 |
| 6400.141(c)(14) | (Repeat from inspection dated 5/10/21): Individual #1's most current physical completed on 1/25/21 did not include Information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 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 |
| 6400.141(c)(15) | (Repeat from inspection dated: 5/10/21): Individual #1's most current physical completed on 1/25/21 did not include If individual #1's has special diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | 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 |
| 6400.144 | 144 (repeat: 1/11/21, 4/26/21, 10/12/21):
Administering expired medications
· During this inspection, the Ear Wax Drops 6.5% prescription available in the home for individual #1 expired on 5/31/21 and were still being administered from June 2021 to November 2021.
Failure to follow doctor recommendations
· On 1/25/21, individual #1 had a video appointment for a physical exam and a pressure injury on individual #1's left hip. Individual #1's PCP requested a picture of the ulcer and information on how it's being treated. During this inspection, TLC confirmed that this information was not provided or relayed to the PCP. During this inspection, TLC was not able to provide verification of the condition or how the ulcer/pressure injury was or is being treated for individual #1.
· On the physical exam appointment form completed on 1/25/21 for individual #1, it states that a Fall Screening is scheduled for 5/24/21. During this inspection, TLC confirmed that this screening was not offered, scheduled, or completed as ordered.
· On 6/10/21, Individual #1 was seen by the urologist for "scratching of the scrotum" where Vaseline was recommended on an as needed basis. During this inspection, TLC confirmed that individual #1 was not offered or administered the following recommendation.
· On 10/26/21, individual was seen by his PCP for a rash in the groin area where Zinc Oxide Barrier Cream was prescribed. During this inspection, TLC confirmed that individual #1 was not offered or administered the following recommendation.
Failure to clarify PRN medication orders
· Individual #1 is diagnosed with constipation. A Bowel Movement (BM) chart, protocol and PRN medication. The BM protocol in individual #1's ISP dated 11/11/21 states that Dylocolax (1 tab) should be administered every 8 hours when there is no BM in 3 days. Individual #1's record contains contradictory information related to the prescribed treatment as follows:
o The BM protocol in individual #1's ISP dated 11/11/21 states that Dylocolax (1 tab) should be administered every 8 hours when there is no BM in 3 days.
o The BM Protocol in individual #1's healthy and safety plan dated 7/20/21 states the Miralax (1 tab) should be administered every 8 hours when there is no BM in 3 days.
o The PRN medication available in the home for constipation was Gavilax Powder which states to administer 17gm once daily as needed.
TLC could not provide a current prescription order for the PRN medication to be administered. Failure to resolve the inconsistency in treatment orders create confusion and an environment conducive to medication errors.
Failure to follow individualized plans
· Individual #1's Health and Safety plan dated 7/20/21, states that the Individual is a fall risk and that all falls should be tracked on the fall tracking form. During this inspection, TLC was not able to provide that individual #1's falls are being tracked. Individual #1 has been hospitalized since 11/29/21 due to falling and fracturing their hip.
· Individual #1's ISP states that they are to have 64 ounces of fluid daily. Per the fluid tracking chart from August 2021 to November 2021, individual #1 wasn't offered nor consumed a total of 64 oz of fluid daily. During this inspection, TLC was not able to produce fluid tracking documentation for the dates of January 2021 to July 2021.
· Individual #1's ISP states that they are on a high fiber diet and should consume 25 -- 35 grams of fiber daily. During this inspection, TLC confirmed that individual #1 is not being offered or consumes the following recommendation.
· Individual #1's Health and Safety Plan states that staff should visually check individual #1 for bruises and to call PCP if bruises exceed 5 centimeters. From January 2021 to November 2021, there were 27 instances where bruises were documented ranging from scratches on the individual's arms, different colors of bruises on their back, chest, wrist, legs, etc. None of the documentation related to the bruising noted the size of the bruises but still indicated concerning, unknown causing of bruises for individual #1. During this inspection, TLC confirmed that no follow up actions related to the bruising were provided for individual #1.
· Individual #1 Health and Safety Plan states to check their Blood Pressure (BP) and Pulse every morning after shower and after sitting in the chair in their bedroom once their shoes and socks are on. During this inspection, the blood pressure and pulse was not being completed at the consistency of this order. The Blood pressure tracking was not tracked in January, February, or August of 2021 and the tracking for March to July, September to November of 2021 were not completed twice as outlined for both.
Failure to seek medical attention
· The health and safety plan also states, if individual #1's BP is above 140/90 or lower than 105/70, the PCP is to be contacted immediately. During the times the BP was documented, there were at least 10 instances where the PCP should have been contacted. TLC confirmed that the PCP was not contacted for these instances.
· Individual #1's Health and Safety Plan states if the pulse is 90 or above to retake the individual's pulse in one hour and if it is still at or above 90 to retake in one hour if it's still at or above 90 to contact the PCP. During this inspection, the pulse was not being completed at the consistency of this order. Between 1/14/21 to 11/29/21, there were 21 times where the pulse should have been retaken or the PCP should have been contacted. | 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.
| 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
| Not Implemented |
| 6400.145(1) | During this inspection, TLC was not able to provide verification of an emergency medical plan for Individual #1 that address the hospital of choice. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | 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 |
| 6400.145(2) | During this inspection, TLC was not able to provide verification of an emergency medical plan for Individual #1 that addressed method of transportation. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | 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 |
| 6400.145(3) | (Repeat from Inspection dated 1/11/21) During this inspection, TLC was not able to provide verification of an emergency medical plan for Individual #1 that addressed 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 inspections dated: 1/11/21, 5/10/21, 10/12/21): Individual #1 had their annual assessment completed on 6/10/20 and not again until 7/20/21 which it outside of the required timeframe. | 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 |
| 6400.181(d) | Individual #1's most recent annual assessment completed on 7/20/21 was not signed and dated by the program specialist. | The program specialist shall sign and date the assessment. | 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 |
| 6400.18(c) | Individual #1 had medication errors on the following dates: 2/18/21. Family was not notified of the medication error. | 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 |
| 6400.32(c) | The violations described in 6400.144, illustrate a systemic failure within TLC to follow doctor recommendations, clarify inconsistencies in PRN medications, seek medical attention when recommended, and follow individual plans. Failures of the above create conditions conducive to harm or injury and constitute mistreatment of Individual #1. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | This occurred due to a lack of communication, monitoring and delegated responsibility for updating the health and safety plans. TLC has begun to include the nursing staff on medical appointment procedure. Program Managers and Program Specialists will be responsible for uploading the appointment documents to the Individual's File Cabinet and emailing them to the nurse. |
03/01/2022
| Implemented |
| 6400.165(g) | (Repeat from inspection dated: 1/11/21, 5/10/21): Individual #1 had a quarterly medication review on 4/21/21 and not again until 8/2/21. Individual #1's quarterly medication reviews completed on 1/20/21 and 4/21/21 were not reviewed by a licensed physician. | 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. | 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 |