| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | REPEAT VIOLATION FROM 12/10/19: The self-assessment for this home is dated 7/31/20, which is outside of the required time frame. The self-assessment is also incomplete. | 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.
| A self-assessment is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/finidings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. |
03/05/2021
| Implemented |
| 6400.103 | There are no written emergency evacuation procedures for this home. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Ensure a calm transition and the safety of people in care in an emergency situation Plans used in the past were found to be inadequate There has been an increased rate of staff and leadership turnover Directors will review the regulation and develop an evacuation template plan that is sufficient for all residents. The Program Managers and Associate Director of Services will tailor to their specific locations. The Director of Compliance and the Residential Directors will meet semi-annually in June and November to review the evacuation plans for the residences. Any necessary corrections will be completed at that time |
03/12/2021
| Implemented |
| 6400.141(c)(6) | The tuberculin test was completed late for Individual #1. It was completed on 1/11/17 and not again until 4/12/19. | 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. | This is important as it mitigates the risk of communicable diseases being presented within the homes The Tuberculin test was not completed in the bi-yearly time frame Various staff and supervisor changes led to inconsistencies within quality of training received and comprehension of regulations The Program Manager will schedule an appointment with the PCP and will have the TB shot completed. The appointment will be uploaded into awards and the TB record will be updated on the persons physical form The residential directors will train all Associate Directors of Services and Program Managers on how to use the Quick look tool. The tool will be implemented to track TB shot records . The Operational ADOS will oversee the implementation of this tool. The Director of Services will complete Semiannual reviews in June and November to review TB Shot Records. Any necessary corrections will be completed at that time |
03/19/2021
| Implemented |
| 6400.151(b) | Staff person #7's physical exam was not dated by the physician.
The annual physical for staff person #9 completed 7/13/20 is signed by the physician, but is not dated by the physician as required. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | It is important that physicians sign and date all their records so that the organization has a record of when the exam took place and there is no opportunity for editing the record to suit the patient's needs The physician did not date the exam record. The opportunity to make an error exists because the dating and signing of the physical does not take place until the TB test is read. This can be 48 to 72 hours after the physical. The HR Office Manager called the Industrial Resource Center to make them aware of this difficulty. They indicated they would retrain the physicians who perform the exams and the staff to remind the physicians to sign and date the proper paperwork. The HR Office Manager will review each physical document assuring it is complete. This is accomplished by his/her initials and date. If the document is not completed correctly, she will call the IRC and arrange for the document to be amended appropriately and then initial and date it upon receipt. |
03/12/2021
| Implemented |
| 6400.151(c)(3) | REPEAT VIOLATION FROM 12/10/19: The annual physical for staff person #9 completed 7/13/20 does not include the language that the Staff is free from communicable diseases.
The annual physical for staff person #11 completed 7/13/20 does not include the language that the Staff is free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | For the safety and well-being of staff members and persons supported by TLC it is imperative that anyone having a physical be diagnosed as free of communicable diseases. The physician failed to include language indicating that the patient is free of communicable diseases the form used by the Industrial Resource Center does not have a check box to indicate the status of a patient's communicable disease. It is an open-ended question for them and this allows for an omission by the physician. The HR Office Manager called the Industrial Resource Center to make them aware of this difficulty. They indicated they would retrain the physicians who perform the exams and the staff to remind the physicians to sign and date the proper paperwork. The HR Office Manager will review each physical document assuring it is complete. This is accomplished by his/her initials and date. If the document is not completed correctly, she will call the IRC and arrange for the document to be amended appropriately and then initial and date it upon receipt. |
03/12/2021
| Implemented |
| 6400.44(c)(1) | There is no indication that Staff Person #3 has 1 year of work experience working directly with individuals with an intellectual disability or autism. | A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with individuals with an intellectual disability or autism. | It is necessary to provide appropriate expertise to the people supported by TLC The resume did not list her IDD experience The person hired into this position indicated their experience during the interview but did not understand the necessity of having it in a written document for TLC's records and compliance with the regulation The person immediately amended their resume. The HR Office Manager will be responsible for initially reviewing the resume or application to assure that the minimum requirements exist for the job being sought. Before an offer is made by the organization, the hiring manager/Director and the HR Office Manager will again recheck that paperwork is complete regarding needed qualifications. |
02/26/2021
| Implemented |
| 6400.46(b) | There is no documentation that staff person #9 attended fire safety training in 2019 or 2020.
There is no documentation that staff person #10 attended fire safety training in 2019 or 2020.
There is no documentation that staff person #11 attended fire safety training in 2019 or 2020. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | It is necessary that staff understand and respond appropriately during any fire emergency. Fire Safety training was not scheduled until the 12th month of the current training year. There was no training scheduled in the organization by the previous trainer or the Director of Quality from August 2019 to April 2020 Fire Training was scheduled in the 12th month (January 2020) of the current training year. Staff was tracked and monitored for completion by the Quality Assistant 1. The organization has hired a Training and Development Coordinator working through the HR Department. 2. TLC has invested in a computerized Learning Management System by Adobe allowing for self-paced training and management of current certifications. 3. A schedule of trainings for the 21-22 year has been established and will be tracked in the Adobe product. 4. The American Red Cross course or a Healthcare First Aid course will be available and tracked by the Quality Assistant during the first quarter of 2021, afterwards within the MLS. All employees will be expected to complete during the first quarter of the educational year (Feb 21-March 21). 5. This will be reported by the Quality Department, while the Learning Management System is built and established and implemented. 6. Training of additional CPR instructors, Medication Trainers and certified SCM trainers will take place in 2021, with each of the ADOS's, PMs and PSs expected to have two of these capabilities within the organization. 7. The respective Directors of Services for Residential and Day programs will coordinate this initiative and report on certifications to the Quality Assistant and the Training and Development Coordinator. 8. Each of the trainers will be responsible for maintaining their certifications and The Training and Development Coordinator will load reminders into the Learning System. 9. Each service area will be responsible for retraining SCM on an annual basis. along with tracking through the Learning System the status of the staff members in their areas of responsibility. 10. Each of the Service Areas will also be responsible for using the LMS to track time frames for medication practicums and enlisting the help of a certified instructor to watch the appropriate number of medication passes to maintain their status of being able to give medications. 11. The 21-22 training schedule will allow for at least 24, but closer to 28 hours of contact hours for education annually. 12. The Quality Coordinator, Quality Assistant and the Training and Development Coordinator will manage a reporting mechanism to the Directors and ADOS personnel indicating the status of assigned trainings, recertifications, certifications, practicums and CPR. 13. Reports on progress will be made during the Quality Meetings held monthly and to the Director's meeting on at least a quarterly basis by the Director of Compliance. 14. The schedule of courses required on an annual basis includes a Fire Safety Training in each educational year for TLC (Feb.-Jan.) |
03/05/2021
| Not Implemented |
| 6400.46(c) | At the time of inspection, there is no documentation verifying that Staff Person #4 was trained in first aid techniques before working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Assignments for education were not done. All direct contact courses like CPR/First Aid and SCM were withheld to help ensure the health of the staff members. Assignments for education were not done. All direct contact courses like CPR and SCM were withheld to help ensure the health of the staff members. The education coordinator resigned in August of 2019 and the Quality Director at the time did not continue the programming as established by a schedule with courses and with in-house department meetings. COVID protocols established by the ARC and TLC prevented face to face meetings for recertification classes Classes were assigned by the Quality Assistant and tracked beginning in June of 2020. As soon as Vaccines are available a fast-paced recertification program will be instituted using all available resources. A paid on-line course will be offered in the first quarter for CPR that allows for a One year window to recertify the physical part of CPR. 1. The organization has hired a Training and Development Coordinator working through the HR Department. 2. TLC has invested in a computerized Learning Management System by Adobe allowing for self-paced training and management of current certifications. 3. A schedule of trainings for the 21-22 year has been established and will be tracked in the Adobe product. 4. The American Red Cross course or a Healthcare First Aid course will be available and tracked by the Quality Assistant during the first quarter of 2021, afterwards within the MLS. All employees will be expected to complete during the first quarter of the educational year (Feb 21-March 21). 5. This will be reported by the Quality Department, while the Learning Management System is built and established and implemented. 6. Training of additional CPR instructors, Medication Trainers and certified SCM trainers will take place in 2021, with each of the ADOS's, PMs and PSs expected to have two of these capabilities within the organization. 7. The respective Directors of Services for Residential and Day programs will coordinate this initiative and report on certifications to the Quality Assistant and the Training and Development Coordinator. 8. Each of the trainers will be responsible for maintaining their certifications and The Training and Development Coordinator will load reminders into the Learning System. 9. Each service area will be responsible for retraining SCM on an annual basis. along with tracking through the Learning System the status of the staff members in their areas of responsibility. 10. Each of the Service Areas will also be responsible for using the LMS to track time frames for medication practicums and enlisting the help of a certified instructor to watch the appropriate number of medication passes to maintain their status of being able to give medications. 11. The 21-22 training schedule will allow for at least 24, but closer to 28 hours of contact hours for education annually. 12. The Quality Coordinator, Quality Assistant and the Training and Development Coordinator will manage a reporting mechanism to the Directors and ADOS personnel indicating the status of assigned trainings, recertifications, certifications, practicums and CPR. |
03/05/2021
| Implemented |
| 6400.46(d) | There is no documentation verifying that Staff person #4 has been trained in First Aid, Heimlich techniques, and CPR.
There is no documentation that staff person #9 is CPR certified. He last had first aid training on 6/14/19 and has not had first aid/CPR training since that date.
Staff person #10 last had CPR training on 1/7/19. There is no documentation that she has had CPR training since that date. | 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. | It is appropriate to train all personnel to be able to respond in a cardiac or choking emergency. This is done to help assure the health and well-being of all supported persons within TLC Assignments for education were not done. All direct contact courses like CPR and SCM were withheld to help ensure the health of the staff members. The education coordinator resigned in August of 2019 and the Quality Director at the time did not continue the programming as established by a schedule with courses and with in-house department meetings. COVID protocols established by TLC prevented face to face meetings for recertification classes Classes were assigned by the Quality Assistant and tracked beginning in June of 2020. As soon as Vaccines are available a fast-paced recertification program will be instituted using all available resources. A paid on-line course will be offered in the first quarter for CPR that allows for a One year window to recertify the physical part of CPR. 1. The organization has hired a Training and Development Coordinator working through the HR Department. 2. TLC has invested in a computerized Learning Management System by Adobe allowing for self-paced training and management of current certifications. 3. A schedule of trainings for the 21-22 year has been established and will be tracked in the Adobe product. 4. The American Red Cross course or a Healthcare First Aid course will be available and tracked by the Quality Assistant during the first quarter of 2021, afterwards within the MLS. All employees will be expected to complete during the first quarter of the educational year (Feb 21-March 21). 5. This will be reported by the Quality Department, while the Learning Management System is built and established and implemented. 6. Training of additional CPR instructors, Medication Trainers and certified SCM trainers will take place in 2021, with each of the ADOS's, PMs and PSs expected to have two of these capabilities within the organization. 7. The respective Directors of Services for Residential and Day programs will coordinate this initiative and report on certifications to the Quality Assistant and the Training and Development Coordinator. 8. Each of the trainers will be responsible for maintaining their certifications and The Training and Development Coordinator will load reminders into the Learning System. 9. Each service area will be responsible for retraining SCM on an annual basis. along with tracking through the Learning System the status of the staff members in their areas of responsibility. 10. Each of the Service Areas will also be responsible for using the LMS to track time frames for medication practicums and enlisting the help of a certified instructor to watch the appropriate number of medication passes to maintain their status of being able to give medications. 11. The 21-22 training schedule will allow for at least 24, but closer to 28 hours of contact hours for education annually. 12. The Quality Coordinator, Quality Assistant and the Training and Development Coordinator will manage a reporting mechanism to the Directors and ADOS personnel indicating the status of assigned trainings, recertifications, certifications, practicums and CPR. |
03/12/2021
| Not Implemented |
| 6400.52(a)(1) | Staff person #9 did not have 24 hours of training in the current training year.
Staff person #10 did not have 24 hours of training in the current training year.
Staff person #11 did not have 24 hours of training in the current training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Assignments for education were not done. All direct contact courses like CPR and SCM were withheld to help ensure the health of the staff members. The education coordinator resigned in August of 2019 and the Quality Director at the time did not continue the programming as established by a schedule with courses and with in-house department meetings. COVID protocols established by TLC prevented face to face meetings for recertification classes. Classes were assigned by the Quality Assistant and tracked beginning in June of 2020. As soon as Vaccines are available a fast-paced recertification program will be instituted using all available resources. A paid on-line course will be offered in the first quarter for CPR that allows for a One year window to recertify the physical part of CPR. 1. The organization has hired a Training and Development Coordinator working through the HR Department. 2. TLC has invested in a computerized Learning Management System by Adobe allowing for self-paced training and management of current certifications. 3. A schedule of trainings for the 21-22 year has been established and will be tracked in the Adobe product. 4. The American Red Cross course or a Healthcare First Aid course will be available and tracked by the Quality Assistant during the first quarter of 2021, afterwards within the MLS. All employees will be expected to complete during the first quarter of the educational year (Feb 21-March 21). 5. This will be reported by the Quality Department, while the Learning Management System is built and established and implemented. 6. Training of additional CPR instructors, Medication Trainers and certified SCM trainers will take place in 2021, with each of the ADOS's, PMs and PSs expected to have two of these capabilities within the organization. 7. The respective Directors of Services for Residential and Day programs will coordinate this initiative and report on certifications to the Quality Assistant and the Training and Development Coordinator. 8. Each of the trainers will be responsible for maintaining their certifications and The Training and Development Coordinator will load reminders into the Learning System. 9. Each service area will be responsible for retraining SCM on an annual basis. along with tracking through the Learning System the status of the staff members in their areas of responsibility. 10. Each of the Service Areas will also be responsible for using the LMS to track time frames for medication practicums and enlisting the help of a certified instructor to watch the appropriate number of medication passes to maintain their status of being able to give medications. 11. The 21-22 training schedule will allow for at least 24, but closer to 28 hours of contact hours for education annually. 12. The Quality Coordinator, Quality Assistant and the Training and Development Coordinator will manage a reporting mechanism to the Directors and ADOS personnel indicating the status of assigned trainings, recertification, certifications, practicums and CPR. |
03/05/2021
| Implemented |
| 6400.169(a) | Staff person #9 was medication administration trained on 8/2/18. There is no documentation indicating that this staff has received medication administration training since that date.
Staff person #10 was medication administration trained on 8/2/18. There is no documentation indicating that this staff has received medication administration training since that date.
Staff person #11 was medication administration trained on 3/15/19. There is no documentation indicating that this staff has received medication administration training since that date. | 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). | This regulation is designed to make sure that staff is appropriately trained in the proper delivery of medications. This takes place through a thorough training and then observation on a regular interval of medication passes in the residential setting. Records of observations by certified med trainers have not been filed properly, nor have they been maintained in a proper manner. The non-centralized use of certified med trainers observing medication passes by staff has resulted in a loss of integrity to the filing and tracking of appropriate observations and training. The Quality Team, where there are 3 certified trainers is in the process of collecting all training records, have completed a spreadsheet for use by the Education and Development Coordinator and are doing observations and proper paperwork for staff in conjunction with other certified med trainers in the organization. The spreadsheet was completed on 2/3/2021 and staff will be trained and up to date on their medication passes, will be complete by 5/31/2021 The Education and Development Coordinator is using the Learning Management System to track due dates and proper observations for all appropriate staff within the LMS. She will be sending reminders to staff at 30 days before their due date, and informational emails to their management staff indicating what needs to be done and when it is due. Anyone not complying will receive from their managers a memorandum of conversation for a first offense and a disciplinary report for any future non-compliance. The Education and Development Coordinator will report results to the Quality Coordinator on a monthly basis and this data will be reported at the Quality Meeting and quarterly to the Directors. |
03/05/2021
| Not Implemented |