|
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 by 2/22/22 |
02/22/2022
| Implemented |
6400.64(d) | At the time of the inspection, there were no trashcans in either bathroom or the kitchen. | Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. | Trash cans were purchased and placed in bathroom and kitchen. · 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). |
02/28/2022
| Implemented |
6400.74 | The bottom two steps of the stairway leading from the parking pad to the front door were missing nonskid surface stair treads. | Interior stairs and outside steps shall have a nonskid surface.
| All nonskid surface steps will have treds placed on them. · 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). |
02/28/2022
| Implemented |
6400.77(a) | At the time of the inspection, there was no first aid kit in the home. | A home shall have a first aid kit. | First aid kit was purchased and placed in the home. · 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). |
02/28/2022
| Implemented |
6400.80(b) | At the time of the inspection, the shed along the front drive way was missing its right-side door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Door was replaced immediately. · 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). |
02/28/2022
| Implemented |
6400.112(a) | (Repeat from inspections dated: 1/11/21, 5/10/21, and 10/12/21)- Individuals lived at the home from January 2021 until 8/20/21. There are no records maintained that the home conducted fire drills. Currently, provider said home was only occupied from 8/19-21/21 but there are incident reports for individuals at this home in June 2021. | An unannounced fire drill shall be held at least once a month. | 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 |
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(c) | There were 3 spray bottles under the kitchen sink that contained water mixed with vinegar and one with water mixed with bleach and they were not in their original labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | Staff will be educated in not storing solutions in containers other than the original at their weekly staff meetings across the residential program. Program Managers under the supervision of the appropriate ADOS-Operational will, monthly look for and assure there are no non-original containers. This will be added to their monthly Safety Checklist. All Residential Program Managers will be retrained on the Monthly Physical Site and Fire Safety Checklist to ensure Poisonous materials shall be stored in their original, labeled containers. See Attachment #68(b) Monthly Physical Site and Fire Safety Checklist. See Training Log Attachment #1 |
02/01/2020
| Implemented |
6400.68(b) | The water temperature was 123F at time of inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On the day of the citation the plumbing company that installed the mixing valve came out and checked and adjusted the valve so water does not exceed the required 120 degrees. Increased testing to daily, temperature must be maintained at 120 degrees or below for 15 days, then to weekly testing. Once the temperature tests are maintained for 4 weeks at 120 degrees or below, regular monthly testing will be put back into place per the Safety Checklist. It will be the responsibility of the Program Manager of the home to ensure this plan of correction is followed. Spread sheet is being created to monitor the water temperature. See attachment #68(b). All Residential Program Managers will be retrained on the Monthly Physical Site and Fire Safety Checklist to ensure water testing is performed on at a monthly basis. If the water temperature is above 120 degrees, a maintenance request will be immediacy submitted to correct the issue. See Attachment #68(b) Monthly Physical Site and Fire Safety Checklist. See Training Log Attachment #1 |
01/31/2020
| Implemented |
6400.82(f) | There was no hand soap in the main bathroom, off of the living room, at the time of inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Soap that is safe to use around individuals have been placed in each bathroom. See Attachment #82(f) Picture. Program Managers under the supervision of the appropriate ADOS-Operational will, monthly look for and assure each bathroom and toilet area that is used has a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. All Residential Program Managers will be retrained on the Monthly Physical Site and Fire Safety Checklist to ensure each bathroom has a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle See Attachment #68(b) Monthly Physical Site and Fire Safety Checklist. See Attachment Training Log 82(f). |
02/01/2020
| Implemented |
|
|