| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 Supplemental Nutritional Assistance Program (SNAP) benefits loaded onto Individual #1 ACCESS card were used on 05/11/21 to purchase $222.56 in groceries from Walmart. These groceries are for the benefit of all individuals who live in the house and not solely for the benefit of Individual #1. | Individual funds and property shall be used for the individual's benefit. | TLC, based on an attached group of documents, does not believe this is a violation. TLC has an approved group home setting. |
02/28/2022
| Not Implemented |
| 6400.22(f) | Typical Life Corporation is Individual #1's representative payee in financial matters. In order to provide funds for Individual #1's cash in the home and purchases of products outside the home, Typical Life Corporation will write checks to home staff members in the amount of the purchase or cash needed and allow staff to cash these checks and provide the resulting cash to the individual. This occurred on 15 different occasions from 1/13/21 through 5/10/21 with checks #1008, 1010, 1011, 1012, 1013, 1014, 1015, 1016, 1017, 1018, 1019, 1020, 1021, 1022, and 1023 written to Staff persons #4 and #5.
On 3 different occasions between 1/13/21 and 5/10/21, checks were written to staff members in excess of the monetary amount needed for the purchase. The resulting change was not returned to the individual until much later than the purchase date. Check #1008 was written to staff in the amount of $20 on 1/13/21 for a cat litter purchase. This item was purchased in the amount of $15.89. Per Fulton Bank records, the remaining $4.11 was not returned to Individual #1 until 2/12/21. Check #1014 was written to staff on 3/10/21 in the amount of $25.00 to purchase cat products. The items were not purchased until 4/10/21 and totaled $19.34. Per Typical Life Corporation register records, the remaining $5.66 was not returned to Individual #1 until 4/16/21. Check #1019 was written to staff in the amount of $25.00 on 4/14/21 to pay for Individual #1's dinner on 4/16/21. This dinner totaled $10.59. Per Typical Life Corporation register records, the remaining $14.41 was not returned to Individual #1 until 4/23/21. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | [The Director of Operations will retrain all staff in TLC's employ on regulation 6400.22f regarding commingling of funds by 9/30/21. Checks will be written and released to the individual for which the funds are for. Checks will be deposited in the individuals' bank account or taken to the bank for cashing with the assistance of TLC staff, when necessary. The P&G (Policy & Procedure and Practice & Guideline) developed and implemented by TLC will be reviewed and updated, as needed, to reflect the procedure above. All staff will receive training on the updated P&G by 9/30/21. Documentation of training shall be kept. Any funds received by an individual shall be recorded immediately on the financial log. The staff member assisting with the transaction is responsible for documentation on the financial log. Financial records should be reviewed by the home supervisor daily.] BR Licensing Supervisor 8/11/21 |
09/30/2021
| Not Implemented |
| 6400.62(a) | Individuals in the home are assessed to be unsafe around poisonous materials. A generic spray bottle with an attached label stating "Faber" hand sanitizer was in an unlocked cabinet in the basement, accessible to the individuals in the home. A Faber hand sanitizer bottle contains a label that states if swallowed, get medical help or contact a Poison Control Center right away. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The staff, ADOS and PM were instructed to replace the container in question and only use an original container. This was done within one week of the citation. They were also told to lock up any poisonous/toxic materials so that they cannot be accessed by individuals. |
08/13/2021
| Not Implemented |
| 6400.62(c) | A generic spray bottled with an attached label stating "Faber" hand sanitizer was in an unlocked cabinet in the basement, accessible to the individuals in the home, and not stored in its original container. A Faber hand sanitizer bottle contains a label that states if swallowed, get medical help or contact a Poison Control Center right away. | Poisonous materials shall be stored in their original, labeled containers. | The staff, ADOS and PM were instructed to replace the container in question and only use an original container. This was done within one week of the citation. They were also told to lock up any poisonous/toxic materials so that they cannot be accessed by individuals. |
08/13/2021
| Not Implemented |
| 6400.64(b) | An amount of 10 or greater bees were swarming around the wooden deck accessible by the sliding door leading from the lower level. | There may not be evidence of infestation of insects or rodents in the home. | Pest Control was called by the Director of Properties, they came and appropriately dealt with the bees and made arrangements to come back and check on the situation during the right times of the year. |
06/04/2021
| Not Implemented |
| 6400.72(b) | The exterior door leading from the garage to the right side of the home, when viewed from the street, has peeling paint, loose molding with cracks and peeling paint, and the door seal is hanging limply off of the side with the doorknob. | Screens, windows and doors shall be in good repair. | Maintenance has or had scheduled the proper repair of this item. |
08/27/2021
| Not Implemented |
| 6400.101 | The interior door leading from the bedroom attached to the bathroom on the upper level, where all the bedrooms are located, is blocked by boxes and clothing and cannot be opened. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Maintenance has or had scheduled the removal or storage of excess material and staff cleared the obstruction during the inspection |
08/27/2021
| Not Implemented |
| 6400.110(a) | At the time of the 05/13/21 inspection, the fire alarm at the front door entrance failed to signal. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Batteries were replaced and Maintenance was called to replace when the system did not work. This was done within 4 days of notification of the failure. |
05/21/2021
| Not Implemented |
| 6400.112(a) | REPEAT from 1/11/21 annual inspection: There are no records maintained that a fire drill was conducted at the home in April 2021. | An unannounced fire drill shall be held at least once a month. | The documentation exists and will only be provided from the automated FORMS spreadsheet. |
03/12/2021
| Not Implemented |
| 6400.112(c) | REPEAT from 1/11/21 annual inspection: The fire drills records from 2/9/21 and 3/2/21 do not include the time the drill occurred. | 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. | The documentation exists and will only be provided from the automated FORMS spreadsheet. |
03/12/2021
| Not Implemented |
| 6400.141(c)(14) | The section titled "Information Pertinent to Diagnosis & Treatment in Case of Emergency (Ex. Mute, tactile defensive, deaf, blind, etc.)" is blank on both the 07/01/19 and 07/07/20 annual physical examination records for Individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This information has been updated and was completed within two weeks of the original citation. |
08/06/2021
| Not Implemented |
| 6400.151(b) | The only physical examination in Staff person #1's record, was not dated by the physician who completed the examination. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | This information has been updated and was completed within two weeks of the original citation. |
08/06/2021
| Not Implemented |
| 6400.151(c)(2) | There are no records maintained that a Tuberculin skin test by Mantoux method with negative results was ever completed for Staff person #1. | 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. | We believe that the vaccination status and the contraindication for TB testing while the vaccination protocols led to a scheduling conflict. TLC should have asked for a waiver, filling out the paperwork for such a request. Staff #1 has had a test. |
07/30/2021
| Not Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 04/21/21 assessment states that the individual "continues to carry money and makes small purchases independently." However, the assessment does not address how much money Individual #1 can carry and if Individual #1 can correctly identify the bills and coins needed to make exact change. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Clinical ADOS will assess the individual's current understanding of currency and coin; ability to make purchases and the amount of staff assistance required. An ISP change form will be submitted to SC and then updated annually via the assessment. |
10/30/2021
| Not Implemented |
| 6400.32(o) | Typical Life Corporation is Individual #1's representative payee in financial matters. In order to provide funds for Individual #1's cash in the home and purchases of products outside the home, Typical Life Corporation will write checks to home staff members in the amount of the purchase or cash needed and allow staff to cash these checks and provide to the individual. This occurred on 15 different occasions from 1/13/21 through 5/10/21 with checks #1008, 1010, 1011, 1012, 1013, 1014, 1015, 1016, 1017, 1018, 1019, 1020, 1021, 1022, and 1023 written to Staff persons #4 and #5. Individual #1 has not consented to this method of disbursement of their personal funds.
Individual #1 SNAP benefits loaded onto Individual #1 ACCESS card were used on 05/11/21 to purchase $222.56 in groceries from Walmart. Individual #1 was not provided the opportunity to manager Individual #1 finances, as provider staff made the purchases for the benefit of the and not Individual #1. The individual has not consented to this use of his funds. | An individual has the right to manage and access the individual's finances. | [All TLC staff will be trained by the Director of Operations on regulation 6400.32o regarding the right to manage and access finances by 9/30/21. The Director of Operations is responsible to review and update the agency's policy on individual funds, ensuring the policy accounts for individual choice and direction. The policy shall be compliant with 6400.22(a). Checks will be written and released to the individual for which the funds are for. Checks will be deposited in the individuals' bank account or taken to the bank for cashing with the assistance of TLC staff, when necessary. The P&G (Policy & Procedure and Practice & Guideline) developed and implemented by TLC will be reviewed and updated, as needed, to reflect the procedure above. All staff will receive training on the updated P&G by 9/30/21. Documentation of training shall be kept. Any funds received by an individual shall be recorded immediately on the financial log. The staff member assisting with the transaction is responsible for documentation on the financial log. Financial records should be reviewed by the home supervisor daily.
SNAP benefits will be used for the individual in which they are assigned unless the individual or individual's guardian has stated otherwise. If the individual/guardian has stated they wish to use the SNAP benefits for the home, documentation of this decision shall be documented by the program specialist and incorporated into the individual's assessment and ISP.] BR Licensing Supervisor 8/11/21 |
09/30/2021
| Not Implemented |
| 6400.46(a) | The are no records maintained for the specific fire safety training provided to Staff person #3 on 5/3/19 and 2/5/21. The record lists that CDS fire safety was completed electronically. However, there are no records that the training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms and notification of local fire department specific to the home Staff person #3 works in, was completed. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Every staff member will be retrained in the items listed in the correction required part of the document. This is taking place location by location as we identify that the information to be imparted is complete and vetted by the appropriate fire safety expert. This will take place before September 1, 2021 |
09/01/2021
| Not Implemented |
| 6400.46(b) | REPEAT from 1/11/21 annual inspection: Staff person #3 received electronic training of fire safety on 5/3/19 and not again until 2/5/21, outside the annual time frame requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Every staff member will be retrained in the items listed in the correction required part of the document. This is taking place location by location as we identify that the information to be imparted is complete and vetted by the appropriate fire safety expert. This will take place before September 1, 2021 |
09/01/2021
| Not Implemented |
| 6400.46(d) | REPEAT from 1/11/21 annual inspection: Staff person #3's training record stated adult cpr/aed/bbp/first aid was completed on 10/21/19 and not again until 2/26/21. There are no records maintained that the 2019 training was completed by a person certified to teach CPR/first aid/Heimlich techniques, the length of time the trainee was certified in said techniques, or that the Heimlich was conducted as part of the training. There are no records that the 2021 training was conducted by a trainer certified to teach said trainings. Staff person #3's 2021 certificate states the training was conducted by the agency, Typical Life Corporation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | [Effective immediately, Staff #3 will not work alone with individuals until they receive training in CPR/First Aid/Heimlich Techniques by a trainer certified by a hospital or recognized health care organization (The American Red Cross, The American Heart Association, The American Safety and Health Institute, The National Safety Council First Aid Institute) The Director of Operations is responsible to ensure Staff #3 is working with another staff member during all shifts until Staff #3 receives training. Documentation of training and trainer credentials shall be kept. The Director of Operations is responsible to develop and implement a tracking methodology to ensure trainings are completed timely. The Director of Operations is responsible to ensure notifications are sent to staff members two months prior to training expiration.] BR Licensing Supervisor 8/11/21 |
09/01/2021
| Not Implemented |
| 6400.50(a) | Staff's training records do not include the amount of time each training took, the trainer who conducted the training or the specific content reviewed during the trainings. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | We are using Adobe's Captivate system to assign trainings and to track new hire trainings and current staff's annual training as detailed in the February Plans of Corrections, which were accepted. We did not go back in time and detail what was done in the system as we acknowledge the records are deficient. This citation will continue to occur on records until we have at least two years of collected data to provide to you in the new system. We believe this citation does not recognize the progress made to comply |
03/19/2021
| Not Implemented |
| 6400.165(g) | REPEAT from 1/11/21 annual inspection: The Psychiatric Appointment on 2/22/21 for Individual #1 does not include the reason for prescribing psychotropic medications Carbamazepine 200mg and Chlorpromazine 200mg. | 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. | CADOS personnel and the TLC RN are reviewing each person's medical information including necessary appointments, accuracy of the Health and Safety plans, the needed screenings for BP and diet along with medications and the required information. This is a monumental task and is being supplemented with outside staffing resources. |
10/30/2021
| Not Implemented |
| 6400.166(a)(11) | REPEAT from 1/11/21 annual inspection: The Medication Admission Record from the month of April, 2021 for Individual #1 does not list the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | All medications will be entered onto the individuals electronic health record prior to the individual being admitted into the residence. This will be done 7-10 days prior and the individual will be marked as inactive until the individual moves into the residence. Weekly medication audits will be performed by staff. MICROSOFT FORMS are available to ADOS to verify that audit was completed. A bi-weekly audit , for a specific amount of mediations, will be done by the ADOS for each location. Quality Coordinator will audit six random individual's medication monthly. This will be reported to the Director of Residential services and the Executive Director. Every staff member, not only at Autumn, but in TLC, that provides Direct Support to persons is being retrained in Medication Training, as per the ODP requirements. There are 179 people requiring this training and as of 6/29, 70+ have been trained and had the two additional observations on top of the two performed during the training, for a total of FOUR (4). Another 20+ have had the training, and are scheduled for their two observations. Up to twenty people are being trained weekly. The expectation is to have all staff retrained and paperwork held in the education office as of September 1, 2021. Observations will be scheduled by staff members and by management personnel on a 6-month recurring basis. Alerts will automatically be sent via the LMS system. |
10/30/2021
| Not Implemented |
| 6400.169(a) | REPEAT from 1/11/21 annual inspection: Staff person #2 has been administering medications to individuals. There are no records that they completed and passed the Department's initial and annual medication administration training. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The prevention of future recurrences and the immediate fix are the same. Each of the trainers have been newly certified or they are not participating as observers. Only one person is providing training. She has trained over 1000 staff members at another provider as part of corrective action. She began training during the inspection in May and provides training for up to 20 staff members weekly in two classes. Observations for TLC will be done only by certified trainers and not by staff who don't have any errors for a 6 month period as has been the case in the past. |
09/01/2021
| Not Implemented |
| 6400.186 | Individual #1 has been assessed to be unsafe with sharp objects, as described in the most recently updated 4/30/21 individual support plan (ISP), "ALL SHARPS WILL REMAIN LOCKED AS WELL AS ALL POISONOUS MATERIAL TO ENSURE THAT [Individual #1] IS SAFE." During the 05/13/21 physical site inspection, a rusty Sawzall blade was found lodged in a blue bucket filled with dirt by the wooden deck, accessible to Individual #1. | The home shall implement the individual plan, including revisions. | Sharps have been locked as CADOS personnel and the TLC RN are reviewing each person's information including accuracy of the Health and Safety plan.. This is a task being supplemented with outside staffing resources. The target date to complete these tasks is October 30,2021. Quality staff and the RN will develop a monitor to determine the accuracy and the implementation success of the plans. This will be in place and designed on or before September, 1, 2021 The rusty blade was removed. Staff were reminded of the need to secure sharps and poisonous materials. |
10/30/2021
| Not Implemented |
| 6400.213(1)(i) | The violation in this description is reference to regulation 6400.213(1)(iv)- Each individual's record must include the following information: The religious affiliation. This regulation number is not accessible at this time in the electronic reporting system but is still an applicable regulation.
REPEAT from 1/11/21 annual inspection: Individual #1's religious affiliation is noted in the record as "other" but does not define this terminology. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Content of the records will be redone by the current program specialist to ensure all appropriate information is updated/ corrected. This will be completed before July 9, 2021 |
07/23/2021
| Not Implemented |