| 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 completed was not dated; not able to verify that it was completed in the correct time frame. | 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 that was completed identified the following violations: 142a. No written summary of corrections 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 |
| 6400.82(f) | At the time of the 1/6/22 inspection, there were no hand towels or paper towels available in the upstairs bathroom of the home. | 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. | Paper towels and hand towels in upstairs bathroom immediately. |
02/28/2022
| Implemented |
| 6400.103 | (REPEAT VIOLATION FROM 1/11/21) The emergency evacuation plans for Individual #1 and Individual #2 did not include individual and staff responsibilities related to evacuation, nor did it include a specific emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| TLC is recreating a written evacuation procedure plan based on the 6400.103 regulation and will be updating all evacuation plans. |
02/28/2022
| Implemented |
| 6400.110(f) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21) Individual #3 utilizes a bed shaker device as they are hearing impaired. During the fire alarm system test at the 1/6/22 inspection, this bed shaker device was not functioning properly. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | TLC checked bed shakers to ensure they're functioning. Staff will be retrained on fire safety including strobe lights, and bed shakers. |
02/28/2022
| Implemented |
| 6400.112(a) | (REPEAT VIOLATION FROM 1/11/21, 10/12/21, 5/10/21) A fire drill was not completed at the home during the month of June 2021. | An unannounced fire drill shall be held at least once a month. | Training on Fire Drill Requirements have been provided to all staff. Quality Department will utilize the Fire Drill Log form which was updated to determine which homes have not completed fire drills and send email to Program Specialist, Program Manager, and Director of Residental to inform them of which homes need to be completed. |
02/28/2022
| Implemented |
| 6400.112(c) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21) The portion of fire drill record for the 1/1/21 and 2/25/21 drills referring to whether or not the strobe light system was operative stated, "N/A strobe lights are not needed in the house because no one has a hearing impairment." This fire alarm system is required to be operative as individual #3 is hearing impaired. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | TLC checked strobe lights to ensure they're functioning. Staff will be retrained on fire safety including strobe lights, and bed shakers. |
02/28/2022
| Implemented |
| 6400.112(d) | (REPEAT VIOLATION FROM 1/11/21) During the 9/9/21 fire drill, Individual #2 failed to evacuate. There is no record that another fire drill was completed in the month of 9/2021. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Training on Fire Drill Requirements have been provided to all staff including educating the individuals upon refusal, documenting this appropriately, and developing a plan of correction for addressing obstacles during evacuation. |
02/28/2022
| Implemented |
| 6400.112(h) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21) It is unclear if all the individuals in this home reached the designated meeting place during the 4/6/21 fire drill as the fire drill record states only "schoolhouse" under the "designated meeting place" portion of the record. | 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. |
02/28/2022
| Implemented |
| 6400.113(a) | (REPEAT VIOLATION FROM 5/10/21) Individuals #1, 2, and 3 have not been trained in fire safety since 10/8/2020. | 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. | The form is completed, and it has been placed in AWARDS under "Fire Safety Training." This happened because moves were not being monitored or followed up with. This has also occurred due to a lack of training on regulations, and lack of accountability. All new fire letters are being sent out after all moves are finalized. |
02/28/2022
| Not Implemented |
| 6400.141(c)(4) | (REPEAT VIOLATION FROM 5/10/21) Individual #2's 9/25/20 and 9/20/21 annual physicals do not include a hearing or vision screening. Individual #2 did have a partial eye exam on 8/27/21, but there are no records maintained that they had an eye examination in 2020. There are no records maintained verifying that Individual #2 had a hearing exam in 2020 or 2021. | 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). TLC will be re-educating all staff on which form needs to be printed out and taken to the appointment on 2/22/22 |
02/28/2022
| Implemented |
| 6400.141(c)(7) | -- (REPEAT VIOLATION FROM 5/10/21) Individual #1's date of admission to Typical Life Corporation was 3/19/18. Individual #1 has not had a gynecological examination completed.
Individual #2's most recent gynecological exam was conducted on 8/23/17. The physician faxed a handwritten statement to Typical Life Corporation on the same date that stated, "Patient's next pap smear will be in 5 years," however, there was no medical reason given for the deferment. This statement also did not address a deferment of a general gynecological exam. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | TLC will be re-educating all staff on requirements for annual appointments. |
02/28/2022
| Implemented |
| 6400.141(c)(14) | (REPEAT VIOLATION FROM 5/10/21) The "medical information pertinent to diagnosis or treatment in case of an emergency" section on Individual #2's 9/20/21 annual physical was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | TLC will be re-educating all staff on which form needs to be printed out and taken to the appointment. |
02/28/2022
| Implemented |
| 6400.142(a) | (REPEAT VIOLATION FROM 10/12/21) Individual #1's date of admission to Typical Life Corporation was 3/19/18. Individual #1 has not had a dental examination.
Individual #2 had a sedated dental exam on 2/11/21. The dentist ordered a 2 week follow-up as well as 6 month exams. Individual #2 has not had any dental exams since 2/11/21. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | TLC will be re-educating all staff on appointment requirements. |
02/28/2022
| Implemented |
| 6400.144 | (REPEAT VIOLATION FROM 1/11/21, 4/26/21, 10/12/21) Individual #1 had a doctor's appointment on 10/30/20 regarding loose stools. The physician indicated that Miralax was to be stopped and the individual was to have a follow up appointment in 2 weeks. Typical Life Corporation discontinued the Miralax, but a follow up appointment was never completed. Typical Life Corporation has continued to track individual #1's bowel movements, but there is no review of this tracking or follow up actions taken. As of the 1/4/22 inspection, Individual #1's current ISP indicates the following: "To prevent constipation, [Individual #1] is given Miralax every 3 days. Staff track [their] BMs. PCP is contacted if concerns arise." Individual #1's bowel protocol on their health and safety plan states, "Bowel movements to be tracked on "bowel elimination tracking" as they occur." Individual #1 did not have any bowel movements on the following dates in 2021: 1/9-1/18; 1/24-2/11; 2/20-3/9; 3/15-3/25; 3/27-3/31; 4/2 -- 4/5; 4/10-4/27; 5/12-5/16; 5/18-5/23; 5/28-5/30; 6/1-6/15; 6/23-7/4; 7/8-7/13; 7/19-8/3; 8/9-8/29; 9/21-25; 10/6-11; 10/18-10/22; 10/26-28; 11/1-11/11; 11/18-11/21; 11/23-11/26; 11/28-11/30; 12/8-12/17. There was no record of any follow-up action when individual #1 went multiple days without bowel movements. After 11 days with no bowel movements, Individual #1 was admitted to the hospital on 12/19/21 with a severe bowel impaction which required surgical intervention.
On 11/4/21, Individual #1 had a medication review completed with Dr. Eike. Dr. Eike indicated that the individual should have a PCP follow-up to determine if individual #1 had a UTI. This follow up exam was not offered, scheduled, or completed.
Individual #1 has a history of self-injurious behaviors. There is not a current approved behavior support plan that is put into place to address these behaviors in order to ensure the health and safety of Individual #1.
Individual #1 was scheduled to have their yearly eye exam on 12/3/21. Staff cancelled this appointment with no indication as to why this appointment was cancelled. As of the 1/6/22 inspection, this appointment has not yet been rescheduled.
Individual #2 was taken to an eye exam on 8/27/21. This exam was unable to be completed. Individual #2's eye doctor recommended an eye exam under anesthesia. As of the 1/4/22 inspection, this examination has not been completed or scheduled.
Individual #2 was prescribed Miralax, which was taken daily until an 8/13/21 gastroenterology appointment. At this time, the physician, Dr. Dachinger, was attempting to determine if the Miralax was needed. Miralax was discontinued with Dr. Dachinger's order to communicate with follow up information regarding the effects of the discontinuance. This follow up was not completed by Typical Life Corporation. Bowel tracking protocol was started on 8/14/21, however, there is no review of this tracking or any follow-up with issues. Individual #2 did not have any bowel movements on the following dates between 8/13/21 and 1/4/21: 8/29 -- 9/7; 9/9-9/14; 9/18 -- 20; 9/22 -- 9/28; 10/9 -- 10/11; 10/19 -- 10/22; 11/3 -- 11/5; 11/10 -- 11/13; 11/18 -- 21; 11/28 -- 11/30; 12/3 -- 12/6; 12/27 -- 12/29; 1/1 -- 1/3.
Individual #2 attends regular podiatry appointments for care of their feet. Individual #2's most recent appointment was conducted on 9/21/21. There have been 2 follow up appointments, on 10/5/21 and 12/7/21, that have been cancelled by staff with no reason given. | 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 has been trained on the importance of documenting and tracking bowel movements whether seen, unseen or reported by individual. Staff will be retrained immediately 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). |
02/28/2022
| Not Implemented |
| 6400.181(a) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21, 10/12/21) Individual #1's date of admission for Typical Life Corporation is 3/19/18. There are no records verifying that Individual #1 has had an assessment completed at any time since their admission date.
Individual #2's most recent annual assessment was completed on 8/30/2020. | 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. | 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 |
| 6400.214(b) | At the time of the 1/6/22 inspection, current assessments and ISPs for Individual #2 and Individual #3 were not available in the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| ISP's and assessments have been placed in the homes. |
02/28/2022
| Implemented |
| 6400.18(c) | Individual #2 had medication errors on the following dates: 5/23/21. 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. | TLC has updated the AWARDS incident form on 01/04/2022 to eliminate the drop down option, "Per requlations 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. |
02/28/2022
| Not Implemented |
| 6400.18(b)(2) | (REPEAT VIOLATION FROM 5/10/21, 6/30/21) The medication errors described in 167a1 and 167a4 were not reported through the Department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | 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). |
02/28/2022
| Implemented |
| 6400.32(c) | Individual #1 has a history of constipation and, in the past, required medication to prevent occurrences. Typical Life Corporation (TLC) failed to seek medical care for Individual #1 as described below:
· Individual #1 had a doctor's appointment on 10/30/20 for loose stools. The physician indicated that Miralax was to be stopped and to schedule a follow up appointment in two weeks. TLC discontinued the Miralax medication but was unable to provide verification of a follow up appointment being offered, scheduled, or completed.
· Individual #1's 1/31/21 ISP reads, "to prevent constipation, [Individual #1] is given Miralax every 3 days. Staff track [their] BMs. PCP is contacted if concerns arise." Between 1/1/21 and 12/19/21, there were at least 24 occasions where individual #1 went three or more days without a bowel movement. There were no follow-up actions taken by TLC when Individual #1 went multiple days without bowel movements.
· Individual #1 was taken to the hospital by their mother on 12/19/21 after they became sick at church. At this time, Individual #1 had gone 11 days without a bowel movement. Individual #1 was admitted to the hospital for a severe bowel impaction which required surgical intervention.
Failure to seek medical care for Individual #1 after numerous days of no bowel movements such that Individual #1 required surgical intervention for a severe bowel impaction constitutes mistreatment.
The violations described in 6400.144, 6400.141c7, 6400.142a, 6400.165g, and 6400.141c4 illustrate a systemic failure to follow doctor recommendations and ensure routine medical care is provided. Failure to ensure medical care is provided and doctor recommendations are implemented constitute mistreatment of Individual #2 and create conditions conducive to harm or injury. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | TLC is reviewing all physician recommendations to ensure they're accurate in the current health and safety plans. |
02/28/2022
| Implemented |
| 6400.34(a) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21) Individual #1's date of admission for Typical Life Corporation is 3/19/18. There are no records verifying that Individual #1's rights were reviewed with them before 5/5/21.
Individual #2's date of admission for Typical Life Corporation is 6/13/14. There are no records verifying Individual #2's rights were reviewed with them before 12/22/21. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Direct staff will review individual rights with all individuals and guardians by 02/28/2022. |
02/28/2022
| Implemented |
| 6400.34(b) | There is no documentation on record verifying that Individual #1's 5/5/21 rights were reviewed with their legal guardian.
There is no documentation on record verifying that Individual #2's 12/22/21 rights were reviewed with their legal guardian. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Direct staff will review individual rights with all individuals and guardians by 02/28/2022. |
02/28/2022
| Implemented |
| 6400.165(f) | Individual #1 and Individual #2 are prescribed medications to treat symptoms of a diagnosed psychiatric illness. There are no written protocols to address Individual #1 and Individual #2's social, emotional, and environmental needs. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | All individuals who are prescribed psychotropic medications will have a SEEN plan developed and placed in the health and safety plan and the ISP. |
02/28/2022
| Implemented |
| 6400.165(g) | (REPEAT VIOLATION FROM 1/11/21, 5/10/21)-The only quarterly medication review conducted for Individual #2 from 1/1/21 to 1/7/22 was completed on 9/1/21. | 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. |
02/28/2022
| Implemented |
| 6400.166(b) | (REPEAT VIOLATION FROM 6/30/21, 10/12/21) The following medications were administered to Individual #1 at the correct time, but they were not documented at the time of administration:
On 8/13/21 at 8pm: Aquaphor, Denta 5000, Metronidazole, Attends
On 10/11/21 at 8pm: Attends, Denta 5000, Quetiapine 300mg
On 11/20/21 at 8pm: Quetiapine 400mg, Attends, Denta 5000
The following medications were administered to Individual #2 at the correct time, but they were not documented at the time of administration:
On 10/11/21 at 8pm: Aripiprazole, buspirone, topiramate
On 11/20/21 at 8pm: Aripiprazole, benzoyl peroxide, buspirone, melatonin, topiramate
On 11/3/21 and 11/17/21 at 6am: Phenytoin | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff will be retrained to document and note reason why there was a late documentation. |
02/28/2022
| Implemented |
| 6400.166(d) | On September 10, 2021, Individual #2's pulmonary sleep physician ordered sulfamethoxaole-tmp to be discontinued. This medication was administered to Individual #2 until 11/1/21.
Individual #2 had dental surgery on 2/11/21. At their pre-op appointment on 2/4/21, Individual #2 was ordered to stop all vitamins from 2/4/21 until 2/11/21 after surgery. Individual #2 was administered Vitamin D3 on 2/8/21 and 2/10/21 at 8am and Multivite on 2/10/21 at 8am. | The directions of the prescriber shall be followed. | Staff will be retrained to on proper documentation, medication discontinuation and disposal. |
02/22/2022
| Implemented |
| 6400.167(a)(1) | (REPEAT VIOLATION FROM 1/11/21, 10/12/21) The following medications were not logged as administered to Individual #1 during 2021:
Melatonin on October 6, 7, 23
Vitamin B on September 30; October 1
Quetiapine 300mg at 8pm on 9/30/21
Attends and Denta 5000 on June 1 at 8am
Daily vite, lisinopril, Probiotic, Vitamin B complex, Vitamin C, and Vitamin D3 on June 28 at 8am
Lisinopril on February 3 at 8am
Vitamin B on March 9 at 8am
The following medications were not logged as administered to Individual #2 during 2021:
Poly Glycol on July 28 at 8am
Poly Glycol, Sulfamethoxazole-tmp, Topiramate, MultiVite, Buspirone, Clindamycin, Vitamin D3, and Loratadine on June 6 at 8am
Phenytoin on June 25 at 6am
All required AM and PM doses of Buspirone from April 16-20 | Medication errors include the following: Failure to administer a medication. | TLC has added into the incident management training that all med errors need to be reported into AWARDS, so that the incident management team is able to enter it into EIM. 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 on a full-time LPN, RN 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 |
| 6400.167(a)(4) | (REPEAT VIOLATION FROM 5/10/21) Individual #1 received the following medications more than one hour before or one hour after the prescribed time in 2021:
Melatonin on the following dates: August 5, 7, 13, 18; October 2, 16, 28, 29, 30, 31; November 2, 4, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29; December 1, 2, 3, 4
Metronidazole on February 7; August 16
Quetiapine on August 14, 17, 18, 19, 20, 21, 24, 26, 27, 28
Aquaphor on February 7, 14; March 6
Daily Vite on March 6
Lisinopril on March 6
Vitamin B on March 6
Vitamin C on March 6
Vitamin D3 on March 6
Denta 5000 on February 7
Individual #2 received the following medications more than one hour before or one hour after the prescribed time in 2021:
Melatonin on September 19; October 5, 11
Aripiprazole on March 28; April 19; July 4, 11; August 16; September 19
Topiramate on April 19; July 4, 11; August 16; September 19
6am Phenytoin on February 6, 7, 13, 19, 20, 21, 22, 27, 28; March 7, 20; April 5, 15, 28; May 20, 23, 26; June 1; September 1
2pm Phenytoin on February 9; March 12, 20; April 23; May 25
8pm phenytoin on April 19
Buspirone on March 28; May 7; July 4, 11; August 16
Rozerem on April 19; July 4, 11; August 16
Miralax on May 7; June 4
Vitamin D3 on May 7
Clindamycin on May 7
Loratadine on May 7 | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | TLC has added into the incident management training that all med errors need to be reported into AWARDS, so that the incident management team is able to enter it into EIM. |
02/28/2022
| Implemented |
| 6400.167(b) | (REPEAT VIOLATION FROM 1/11/21) There is no documentation maintained that the medication errors described in 167a1 and 167a4 were reported to Individual #1's or Individual #2's physician. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | TLC has added into the incident management training that all med errors need to be reported into AWARDS, so that the incident management team is able to enter it into EIM. Nurses have also been added to the procedure of updating the health and safety plans following medical appointments to ensure orders are being updated appropriately. |
02/28/2022
| Implemented |
| 6400.167(c) | (REPEAT VIOLATION FROM 10/12/21) The medication errors described in 167a1 and 167a4 were not reported as incidents for Individual #1 or Individual #2. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | TLC has added into the incident management training that all med errors need to be reported into AWARDS, so that the incident management team is able to enter it into EIM. |
02/28/2022
| Not Implemented |
| 6400.181(f) | There are no records verifying Individual #1 has ever had an assessment completed by Typical Life Corporation, therefore, there is no verification that an assessment has been provided to their plan team for individual plan meetings. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialists will be retrained on annual assessment requirements per the 6400 regulations. Quality contacted the Program Specialist of each individual who needs an updated assessment as well as the Director of Residential Services. |
02/28/2022
| Implemented |
| 6400.183(c) | Typical Life Corporation has no record of the list of persons that attended Individual #1's 2021 plan meeting.
Typical Life Corporation has no record of the list of persons that attended Individual #2's 2020 or 2021 plan meetings. | The list of persons who participated in the individual plan meeting shall be kept. | Program Specialists will be retrained on ISP meeting requirements, including which documents to obtain and upload with individual's plans. |
02/28/2022
| Implemented |
| 6400.195(b) | Individual #2's restrictive behavior plan was reviewed and approved by a human rights team on 1/22/21 and not again until 12/23/21. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | All BSPs have been reviewed and are in the process of being updated by the Director of Behavioral Services. Staff have been trained on the BSP/ RPP 02/09/2022 and Director of Behavioral Services has been in the house completing observations in order to ensure the plan is being followed appropriately. TLC created Human Rights Team and held to review and approve the RPP. |
02/28/2022
| Implemented |
| 6400.213(1)(i) | The photograph available in Individual #1's record is dated 5/17/19.
The photograph available in Individual #2's record is dated 2/3/20. | Each individual's record must include the following information: Current, Dated Photo | Program Managers will take updated photos of all individuals in their service areas by 02/28/2022 |
02/28/2022
| Not Implemented |