| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(18) | Staff #1's first date working at Fenwick Drive was 10/5/16 and she was not trained in Individual #1's Individual Support Plan (ISP) until 1/25/17, Behavior Intervention Plan until 12/26/16, plan to address Individual #1's social, emotional, and environmental needs until 12/27/16, or dental hygiene and supervision plans until 11/22/16. Staff #2's first date working at Fenwick Drive was 11/27/15 and Staff #3's first date working there was 1/6/17. Neither Staff #2 or #3 were trained in Individual #1's ISP, behavior intervention plan, dental plan, supervision plan, or protocol to address Individual #1's social, emotional, and environmental needs. Staff #6's first date working at Fenwick Drive was 1/30/17 and he was not trained in Individual #1's ISP. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | The Program Specialist (Clinical Associate Director of Services) will ensure that all staff providing supports to individuals will review the ISP and sign the training log . See Attachment email 44(b)(18) Per licensing regulation 44(b)(18): The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual.Please ensure that the ISP is reviewed with all new staff prior to providing supports to individuals and the training log is signed. Typical Life will holding an all staff meeting on Wednesday July 5, 2017. During this meeting all staff will be trained on the importance of signing documentation pertaining to Health and Safety of individuals, Training Logs, etc... The staff meeting minutes will be submitted to you by no later than July 7, 2017. |
07/07/2017
| Implemented |
| 6400.46(a) | Staff #6's date of hire was 8/1/16 and there wasn't documentation that he was trained in residential job responsibilities and daily operations of the residential home. Information was requested from residential multiple times since 3/13/17. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Staff #6's date of hire was 8/1/16. See Attachment 46(a) Job Description dated 8/1/2016 Pages 1,2 and 3. See Policy New Employee Orientation Page 4 and Page 5. See Orientation Checklist for Staff #6 dated 8/5/2016 Attachment 46(a) Page 6 and Page 7. |
06/15/2017
| Implemented |
| 6400.46(d) | Staff #2 only received 23.75 hours of training in the training year. | 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. | Staff #2 received 24.75 hours of training in the training year. See Attachment 46(d) which is the Training Record for Staff #2. The second page has an hour of training listed on it which may have been missed when the record was reviewed. |
06/15/2017
| Implemented |
| 6400.46(e) | Staff #6's date of hire was 8/1/16 and there wasn't documentation that he was trained in individuals' rights and program planning and implementation. Information was requested from residential multiple times since 3/13/17. | Program specialists and direct service workers shall have training in the areas of Intellectual Disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Staff #6 was trained in individuals' rights and program planning and implementation. See Attachment 46(e) Page 1 and Page 2. |
06/16/2017
| Implemented |
| 6400.62(a) | Individual #1 was not assessed to be safe around poisonous materials. The cleaning substance Spic and Span Antibacterial spray that contained a label to contact poison control center if ingested, was unlocked and accessible on the fireplace mantle upon arriving to the home. Many other cleaning supplies that contained the label to contact poison control center if ingested were found unlocked and accessible in the garage; Clorox Disinfecting wipes, 14 small cans of latex paint and 2 -32 ounce containers of wood stain. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Individual #1 is not safe around poisonous materials. Typical Life will holding an all staff meeting on Wednesday July 5, 2017. During this meeting all staff will be trained on the importance of Poisonous materials being kept locked or made inaccessible to individuals that are assessed as being unsafe. All staff need to make sure if the individuals they work with are assessed as being unsafe with poisonous materials they MUST be kept locked at all times. The staff meeting minutes will be submitted to you by no later than July 7, 2017. See the Attachment 62(a) which is an email "Fenwick Cite." Chapter 6400 Physical Site Checklist Page 2 Section 62(a) already reflects the importance inaccessibility of Poisonous materials to individuals that are assessed as unsafe. - See Attachment Chapter 6400 Physical Site Checklist Page 2. This Checklist will also be reviewed with the ADOS's at the next Quality Meeting that will be held on July 10, 2017. |
07/10/2017
| Implemented |
| 6400.67(a) | The laundry room was filled with approximately a 5 foot in diameter puddle of water. According to staff, this puddle of water floods the laundry room often. The doors on the storage unit in the garage were off the tracks and the doors were fallen in on the shelves. The latch on the sliding glass door was extremely bent, making it very difficult to open the door. There was approximately a 2 foot hole in the drywall under the spigot in the garage. The basement floor tiles were loose, pealing up from the floor and chipped. | Floors, walls, ceilings and other surfaces shall be in good repair. | Please see Attachment 67(a) email Fenwick Cites Page 1 and Page 2 - that states: The laundry room plumbing was professionally snaked/cleaned in March. As of today Steve has not been out there for this issue, and I have not seen it being reported on a maintenance report. In regards to the flooring email Fenwick Cites states: I will have Steve reach out to our floor guy to take care of the basement flooring. It will be done within the next month.
The doors on the storage unit in the garage has been placed back on the tracks and the doors are no longer falling in on the shelves. See Attachment 171 Page 1 and 2.
The latch on the sliding glass door has been removed. See Attachment 101 Page 3 sliding glass door.
The 2 foot hole in the drywall under the spigot in the garage has been fixed. Please see Attachment 67(a) Page 3 . |
06/15/2017
| Implemented |
| 6400.72(b) | The closet door in the basement was missing a door knob. The door knob was found on the floor. Individual #1's closet doors in his/her bedroom were not on the door track system. The doors were leaning in on his/her clothes hanging up in the closet. | Screens, windows and doors shall be in good repair. | Door knob was put on basement closet door. See attachment #216(a) Page 2. Individual #1's closet doors in his/her bedroom have been put back on the track system and a new closet door "guide" has been attached on the floor so the doors for the closet are now stable. See Attachment 72(b) page 1,2 and 3. t Chapter 6400 Physical Site Checklist has been updated- See Attachment Chapter 6400 Physical Site Checklist Page 6. |
06/15/2017
| Implemented |
| 6400.101 | REPEAT from 10/26/16 renewal inspection: One of the garage exit doors was blocked by a tub of food sitting on the floor. The basement exit door was locked with a key entry lock without having the key permanently affixed in or near the lock. Staff indicated that they did not know where the key to the door was located. The sliding glass door contained a key lock without the key permanently affixed in or near the lock. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Tub of food sitting on the floor in front of the garage door exit has been removed. See Attachment 101 Page 1. All deadbolts have been removed from all doors. Individual #1 no longer resides at the Fenwick home. See Attachment 101 Page 2 and Page 3 front door and sliding glass door. Chapter 6400 Physical Site Checklist has been updated- See Attachment Chapter 6400 Physical Site Checklist Page 13 to reflect **Note; All doors should be fully functional and easily opened-All doors MUST be free from obstructions, such as bins, debris, etc...
Explanation: This does not apply to exits from the home if all three of the following conditions are met: the exit is never used, and, the exit is not accessible and does not have the appearance of being an exit, and, there are at least two other useable exits from that floor. Doors may not be locked with dead bolts that are operated by a key, unless the key is permanently affixed in or near (e.g. key on chain along side lock with chain permanently bolted to wall or door) the lock. |
06/15/2017
| Implemented |
| 6400.113(a) | Individual #2 received general fire safety training on 7/2/15 and not again until 10/24/16. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home. | Individual #2 has received general Fire Safety Training again on 6/14/2017. See ATTACHMENT 113(a) Page 1. As of May 9, 2017 Typical Life has implemented that general Fire Safety Training must be done in the months of April and October. Please see Attachment 113(a) email "Fire Safety Training" date May 9, 2017. This has also been added to the Fire Drill Log. See Attachment 113(a) Fire Drill Log. |
06/15/2017
| Implemented |
| 6400.141(c)(3) | Individual #1's 10/21/16 physical examination form did not contain any immunizations. The agency did not obtain any immunization records until 3/8/17. | 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. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section #8 to reflect Individual#1's immunizations. See Attachment 141 Page 1 and Page 2 "Physical". See Attachment 141(c)(3) "Immunization Record" with Individual #1's immunizations listed. Existing Program Specialists (Clinical ADOS's) have been emailed to remind them of the importance of Immunization records being obtained and current prior to admission. See Attachment email 141(c)(3) Individual's Physical dated June 14, 2017. See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly.
All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.141(c)(4) | Individual #1's 10/21/16 physical examination form did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section 13 and 14 to reflect Individual#1's Vision and Hearing Screening. See Attachment 141 Page 1 and Page 2 "Physical". See Attachment 141(c)(4) "Medical Form" with Individual #1's Vision and Hearing screening listed. See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly. All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's 10/21/16 physical examination form did not include a Tuberculin skin test with negative results. The agency did not obtain Tuberculin skin testing results for Individual #1 until 3/8/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section 4 to reflect Individual#1's Tuberculin skin test with negative results. See Attachment 141 Page 1 and Page 2 "Physical". See Attachment 141(c)(6) "White Rose Family Practice" with Individual #1's Tuberculin skin test with negative results dated for 3/22/17. See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly. All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.141(c)(10) | Individual #1's 10/21/16 physical examination form did not include if he/she was free from communicable disease. | 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. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section 17 to reflect Individual#1's free from communicable disease results . See Attachment 141 Page 1 and Page 2 "Physical". See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly. All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.141(c)(12) | REPEAT from 10/26/16 renewal inspection: Individual #1¿s 10/21/16 physical examination form did not include physical limitations. The field was blank. | The physical examination shall include: Physical limitations of the individual. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section 9 to reflect Individual#1's include physical limitations of the individual results . See Attachment 141 Page 1 and Page 2 "Physical". See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly. Note Section 9 Physical Limitations has been removed and is now reflected under Section 23 on the revised Physical Form .
All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.141(c)(13) | Individual #1's 10/21/16 physical examination form did not include his/her allergies or contraindicated medications. The field was blank. | The physical examination shall include: Allergies or contraindicated medications. | Individual's #1 Physical was given back to doctor on 3/22/2017. Typical Life asked for corrections to be made on the Physical Form, section 6 to reflect Individual#1's allergies or contraindicated medications results . See Attachment 141 Page 1 and Page 2 "Physical". See Attachment "141 Physical Examination Form" which has been revised to reflect the following: All Sections of the Physical Form must be completed. No blank spaces are permitted. Attach any related documentation such as: TB Results, eye exams, Mammogram exams, Prostate exams, etc. It is the responsibility of the Program Manager or ADOS to attend the Physical Appointment and ensure the Physical Form is completed correctly.
All Program Manager's or ADOS's are now responsible to attend Physical Appointments and will be expected to use the Physical and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.151(b) | Staff #1's 2/15/16 physical exam form did not contain legible information that indicated if his/her physical was competed, signed and dated by a physician, certified nurse practitioner or licensed physician's assistant. The agency was instructed to send information clarifying who completed Staff #1's physical to the licenser however none was received by the licenser. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical examination has been revised to have a section that shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. See Attachment 151(b) and 151(c)(2). |
06/15/2017
| Implemented |
| 6400.151(c)(2) | Staff #1's 2/17/16 Tuberculin (TB) skin testing form did not contain legible information that indicated if his/her TB was competed, signed and dated by a registered nurse, licensed practical nurse, licensed physician, licensed physician's assistant or certified nurse practitioner. The agency was instructed to send information clarifying who completed Staff #1's physical to the licenser however none was received by the licenser. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The physical examination has been revised to have a section that shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. See Attachment 151(b) and 151(c)(2). |
06/15/2017
| Implemented |
| 6400.168(a) | REPEAT from 10/26/16 renewal inspection: Staff #3 was certified by a medication trainer on 6/6/16 to administer medications to individuals. However, Staff #3 did not complete the Department's required 4th medication observation until 6/15/16, after he/she was "certified." | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff number 3, completed his 4th med review in the month of May - the June 15 date in question is the date the document was filled out - as med logs are not submitted for review until after the month is done - Certified Med trainer reviews med logs in the first two weeks of the month after logs are submitted - Staff 3 completed all portions of the required med training prior to June 6th. See Attachment #168(a). Pages 1-12. |
06/15/2017
| Implemented |
| 6400.171 | Containers of wood stain were stored on the shelf above food stored in the garage. Food items such as oranges, granola bars, and boxed food was found in a bin on the floor in the garage without a lid. | Food shall be protected from contamination while being stored, prepared, transported and served.
| All containers of wood stain are now stored in a storage unit in the garage. Food items such as oranges, granola bars, and boxed food have removed from the garage and place inside the home in appropriate cabinets/refrigerator. See Attachment 171 Page 1 and 2. See email attachment 216(a) Page 3. See Attachment 216(a) Staff Meeting Minutes for Fenwick and Butter Road-where Individual #1 now resides. All other Staff Meeting minutes are available if needed. |
06/15/2017
| Implemented |
| 6400.181(a) | Individual #1's date of admission to the facility was 11/21/16 and at the time of the inspection on 3/13/17, he/she still did not have an assessment completed for him/her. Individual #1 was approved for 1:1 staffing on 11/21/16 and then 2:1 staffing on 1/4/17 and another updated assessment should have been created for the change in service needs.
?At the time of the unannounced inspection on 3/13/17, Individual #2's last assessment completed for him/her by the program specialist was on 2/24/16.
| 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. | Individual #1's date of admission to the facility was 11/21/16 and at the time of the inspection on 3/13/17, he/she still did not have an assessment completed for him/her. An Assessment for Individual #1 was completed on 2/3/2017 but never filed in his ISP Book.See Attachment 181(a) Send out letter. See Attachment 181(a) 60 Day Assessment Summary
In regards to "Individual #1 was approved for 1:1 staffing on 11/21/16 and then 2:1 staffing on 1/4/17 and another updated assessment should have been created for the change in service needs" - An Addendum to the Assessment was completed on 6/16/2017 to reflect the 2:1 staffing on 1/4/17. See Attachment 181(a) Page 1. The Assessment template will be updated by 6/30/2017 to reflect guidelines in regards as to when an Assessment is required to be completed. The Assessment template will be sent to you by no later than close of business 6/30/2017.
At the time of the unannounced inspection on 3/13/17, Individual #2's last assessment completed for him/her by the program specialist was on 2/24/16. An Assessment was completed on 2/13/2017 but never filed in his ISP Book. See Attachment 181(a) Page 2. Typical Life will ensure that Individual #2 reviews and signs his 2017 Annual Assessment and the Assessment will be place in his ISP Book. We will send you the signed copy of 2017 Annual Assessment Signature page no later than 6/30/2017. |
06/30/2017
| Implemented |
| 6400.181(c) | Individual #2's 2/24/16 assessment did not indicated if it was based on assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Existing Program Specialists (Clinical ADOS's) have been emailed to remind them of the importance of basing the Assessment on assessment instruments, interviews, progress notes and observations. See email 181(c) Annual Assessment dated June 14, 2017. The Assessment Checklist has also been revised to reflect the following: Was the Assessment based on assessment instruments, interviews, progress notes and observations. All Program Specialists (Clinical ADOS's) will be expected to use the Assessment Checklist and follow the guidelines it contains. |
06/15/2017
| Implemented |
| 6400.181(f) | Individual #2's 2/24/16 assessment was not sent to him/her and his/her team members 30 days prior to his/her 4/4/16 Individual Support Plan (ISP) meeting. Individual #1's assessment was sent on 3/28/16. | (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).
| Individual #2's 2/24/16 assessment was sent to him/her and his/her team members 30 days prior to his/her 4/4/16 Individual Support Plan (ISP) meeting. See Attachment 181(f) Page 1, Send out letter for 2016 Assessment dated 2/24/2016. See Attachment 18(f) Page 2 County Letter stating ISP Annual Review date of 4/4/2016. |
06/15/2017
| Implemented |
| 6400.183(4) | Individual #1's Individual Support Plan (ISP) did not include a protocol to include the current level of supervision needs and method of evaluation used to determine progress towards a higher level of independence. Individual #1 required 2:1 staffing however his/her ISP indicated he/she was only being supported with 1:1 staff and a request for 2:1 staffing was made. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | An Addendum to Individual #1's Individual Support Plan (ISP) has been submitted to Individual #1's SC and members of his Support Team to reflect the following: Supervision Care Needs:
Please REMOVE Home Supervision and REPLACE with - ¿Individual #1 requires 24 hour supervision in his home. Support staff must be aware of Individual #1's whereabouts within the home at all times; however, Individual #1 is safe to be alone in his bedroom. Due to challenging behaviors including elopement, physical aggression, and sexual touching; Individual #1 receives 2:1 staffing Monday - Friday 7am to 11pm and Saturday - Sunday 7am to 3pm. Providing 2:1 staffing helps Individual #1 safely integrate into his community and protects his health and safety as well as the health and safety of others. If Individual #1's challenging behaviors were to decrease, he could advance in his level of independence and reduce staffing.¿ See Attachment 183 Page 1 and Page 2. |
06/16/2017
| Implemented |
| 6400.183(5) | Individual #1's protocol to address his/her social, emotional and environmental needs did not include symptoms of his diagnoses schizophrenia, psychosis NOS, obsessive compulsive disorder, impulse control disorder, and anxiety. His/Her plan also did not address the social, emotional and environmental needs Individual #1 has due to the symptoms of his/her diagnoses. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: 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. | An Addendum to Individual #1's Individual Support Plan (ISP) has been submitted to Individual #1's SC and members of his Support Team to reflect the following: Behavioral Support Plan:
Please ADD to Plan to Address Social, Emotional and Environmental Needs - ¿The plan to address the social, emotional and environmental needs of Individual #1 is:Individual #1 is prescribed psychotropic medications to address the symptoms related to his mental health diagnoses of Schizophrenia, Psychosis NOS, Obsessive Compulsive Disorder, Impulse Control Disorder, and Anxiety. Individual #1 is monitored by his psychiatrist at least quarterly to ensure his medications remain at a therapeutic level.
Symptoms associated with Individual #1's mental health diagnoses may include irritability (manifested as pulling and pushing staff and physical aggression such as hitting and kicking), mood lability, and hyper sexuality (manifested as touching another¿s groin area).¿
See Attachment 183 Page 1 and Page 2. |
06/16/2017
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) indicated he/she had a plan to address social, emotional and environmental needs along with a behavior intervention plan. Both plans indicated the requirement to track behavior data. The behavior data for the entire day on March 1st, 10th, and 11th, 2017 was missing from Individual #1's record. The tracking logs for December 2016-February 2017 did not indicated antecedents to behaviors, redirection techniques, number of times a behavior was witnessed, or the outcome of the redirection techniques used. | The ISP shall be implemented as written. | An Email was sent to Individual #1's Behavioral Therapist and Operational ADOS to address this Cite. Please see Attachment 185(b) email Re: Behavioral Plan for Individual #1 Page 1 and Page 2. The Behavioral Support Plan and Training Log will sent to you no later July 14, 2017. |
07/14/2017
| Implemented |
| 6400.212(b) | Staff #5 completed information on Individual #1's 10/21/16 physical examination form but did not indicate date of when the entry was made. | Entries in an individual's record shall be legible, dated and signed by the person making the entry. | A statement was added to the Physical Form Checklist stating: All Entries on the Physical record shall be legible, dated and signed by the person making the entry.
See Attachment 212(b). Staff #5 has separated from the company. Due to this separation Staff #5 was unable to correct this non-compliance and unable to notify Typical Life as to when this entry was made. |
06/15/2017
| Implemented |
| 6400.213(1)(i) | Individual #1¿s record did not contain his/her religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Clinical ADOS-Brittany Barlow has contacted Individual #1's mother in regards to his religious affiliation. This information has been added to his/her record. See Attachment 213(1)(i) . All staff were trained on 6/14/2017 on the importance of this information being on the individuals records. See email attachment 216(a) Page 3. See Attachment 216(a) Staff Meeting Minutes for Fenwick and Butter Road-where Individual #1 now resides. All other Staff Meeting minutes are available if needed. |
06/15/2017
| Implemented |
| 6400.213(11) | REPEAT from 10/26/16 renewal inspection: Individual #1's Individual Support Plan (ISP) indicated in the "meals and eating" section that he/she did not have allergies however the allergy section of the ISP indicated he/she was allergic to codeine. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | An Addendum to Individual #1's Individual Support Plan (ISP) has been submitted to Individual #1's SC and members of his Support Team to reflect the following: Meals and Eating:
Please CHANGE TO READ - ¿Individual #1 does not require any special preparations as he has no allergies to food and is not considered to be a choking risk when eating edible food. Choking is only a concern when eating a non-edible item due to PICA behaviors.¿ See Attachment 213(11) Page 1 and Page 2. |
06/16/2017
| Implemented |
| 6400.216(a) | REPEAT from 10/26/16 renewal inspection: Individual record information for an individual who previous lived at the residence was found unlocked and accessible in the basement. Individual #2's Individual Support Plan (ISP) and other record information was also unlocked and accessible in the basement. | An individual's records shall be kept locked when unattended. | Information was secured in locked Staff Office upstairs. The old file/binder was disposed of and lock was put on basement closet door. See attachment #216(a) Page 1 & 2. All staff were trained on 6/14/2017 on the importance of keeping all records locked when not being used. See email attachment 216(a) Page 3. See Attachment 216(a) Staff Meeting Minutes for Fenwick and Butter Road-where Individual #1 now resides. All other Staff Meeting minutes are available if needed. |
06/15/2017
| Implemented |