| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(6) | ISP and ISP reviews indicted the restrictive plan was d/c'd but the phone remained locked in the staff office, family visits were supervised, and phone calls to mom and dad were only 15 minutes and not on the same day. - This is not occuring or accurate. THe PS needs to review the ISP for content accuracy and report discrepancies. | The program specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions under § 6400.186 for content accuracy. | Proper monitoring and oversight was not provided to ensure content discrepancies do not occur. A change was made to the restrictive plan and was not documented properly in the ISP. TLC understands that the ISP must not contain any content discrepancies and all information is consistent. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved. See Attachment #12 Email and Addendum to ISP send to Support Coordinator. Sent on 12/11/2018 to York IDD Supports Coordinator. It will be the responsibility of all Clinical ADOS's to ensure ISP's reflect current information. This will also be monitored annually during the time the ISP is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the ISP. Additionally this will be monitored quarterly during ISP Reviews.This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. |
01/31/2019
| Implemented |
| 6400.66 | The downstairs egress route had an inoperable light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| An Individual within the home had placed a wreath by the light sensor which prevented the motion sensor light to operate correctly. Resolved on 11/20/2018 . This regulation was reviewed with the staff in the home and further noncompliance will result in appropriate HR disciplinary action. On 12/2018 the Chapter 6400 General Safety and Fire Safety Checklist was revised to ensure proper oversight. The date of the revised safety checklist is indicated on the form. See Attachment #1 Completion of the Chapter 6400 General Safety and Fire Safety Checklist is the responsibility of the Operational ADOS/Program Manager to be completed monthly. This Checklist will be submitted to the Quality Department by the 5th of each month for review of compliance. Members of the quality management team will randomly check residences to ensure the residences are remaining compliant. All Program Managers will be trained in the use of the Chapter 6400 General Safety and Fire Safety Checklist as part of their new employee orientation and also management orientation. A Practice and Guideline will be implemented for reference on how to complete the Chapter 6400 General Safety and Fire Safety Checklist Typical Life Corporation will also be rolling out person centered planning (PCP) training for all staff. In the training staff will learn about PCP thinking and tools they can use to support individuals. This will help staff identify how they can support individuals with challenging behavior. The use of PCP will be evidence through the use of PCP tools documented in the person's record. Training records will also document the progress of rolling this training out to all staff. We expect this to be a long term effort over the next eighteen months and we plan to incorporate this into new employee orientation. TLC has also made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Managers will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. |
01/31/2019
| Implemented |
| 6400.67(a) | The tv stand had several large divots with chunks of wood missing. Bedroom # 2's closet trim was ripped off. | Floors, walls, ceilings and other surfaces shall be in good repair. | A piece of furniture in disrepair was not disposed of with a new one replacing it and missing trim was not replaced. The Program Manager of the home did not recognize the need to replace the furniture or to replace the missing trim. Bedroom #2's closet trim was replaced on 11/28/2018 by the Maintenance Department. See Attachment 67a picture of replaced trim. The TV Stand has been replaced with a stand that meets this regulation. See Attachment #67a picture of new tv stand. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. A training will occur with all program managers and operational ados to review how to do physical cite reviews, to include recognizing furniture in disrepair, damage to house, etc.. to ensure this regulation is complied with to ensure individuals are living in a safe, well cared for home. The Safety Checklist has been revised to ensure proper oversight. On 12/2018 the Chapter 6400 General Safety and Fire Safety Checklist was revised to ensure proper oversight. The date of the revised safety checklist is indicated on the form. See Attachment #1. Completion of the Chapter 6400 General Safety and Fire Safety Checklist is the responsibility of the Operational ADOS/Program Manager to be completed monthly. This Checklist will be submitted to the Quality Department by the 5th of each month for review of compliance. Members of the quality management team will randomly check residences to ensure the residences are remaining compliant. All Program Managers will be trained in the use of the Chapter 6400 General Safety and Fire Safety Checklist as part of their new employee orientation and also management orientation. A Practice and Guideline will be implemented for reference on how to complete the Chapter 6400 General Safety and Fire Safety Checklist Any non compliances found will be referred to the maintenance department through the Maintenance Request Form. This form is reviewed daily by the maintenance department and prioritized for repair. Once repaired, the maintenance request is closed. The Quality Department will monitor the Maintenance Request Form to ensure any physical site non compliances are resolved on a timely basis. Effective 2/1/2019 the Program Managers will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. |
01/31/2019
| Implemented |
| 6400.144 | Medication Omissions occurred as follows for Individual #1:
3/16, 3/17- Gavilax Powder 17 grams -- "no med in bottle or refill for 8am."
2/9/18- Gabapentin 100/0/0/100 to 200/0/200/0. Not completed until 2/13. Lamotrigine 200/0/0/175. -- done on 2/12.
3/5/18- Abilify changed from 0/0/0/30 to 0/0/0/15, Latuda 20/0/0/0 1 week then increase to 40mg. --Latuda started 3/9/18. Abilify started 3/9/18.
3/19/18- Famotidine 20mg BID 7 days. Started 3/22.
4/19/18- Benztropine omission.
4/23/18 -- omission of 120mg of Latuda.
5/11/18- all 8am med omission.
6/1/18-6/4/18 -- melatonin not administered -- pharmacy didn't deliver.
6/9/18 Benztropine 1mg and Propranolol ER 120mg -- omission- on outing, didn't have meds.
6/23/18 - Omission of Benztropine 1mg and Propranolol ER 120mg.
11/12/18 - omission of Lamictal, Propranolol, Saline MIst, Polyethylene glycol. | 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.
| Farm Lane staff including management will be retrained by 1/31/2019 on Medication Administration. It will be the responsibility of the Operational ADOS and Program Managers to ensure all medications on MAR's are administered correctly and no discrepancies are noted. Training Specialist will train all Program Managers on the correct way to have MAR'S completed to ensure all medications on the MAR'S meet this regulation. The Medication Audit form has been revised to ensure proper oversight. This form will be submitted monthly by the 5th of each month to the Quality Department to be reviewed. See Attachment #3 Medication Audit Form. An Internal incident report will be submitted for any omissions/omissions of signatures so appropriate HR action can be taken. Any omissions of medication will be entered into the EIM System in the appropriate time frame. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. An Internal review of Medications was performed by the HR Director and another Certified Investigator to determine the root cause of these errors. All medication errors wiIl be entered into the EIM system. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. |
01/31/2019
| Implemented |
| 6400.164(b) | 7/8, 7/13, 7/21 -- Ketoconazole 2% shampoo- no signatures. -- back of log indicated omission of signatures.
6/26/18- omission of signature for Minocylcine 100mg and Fibercon 625mg for Individual # 1 | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Farm Lane staff including management will be retrained by 1/31/2019 on Medication Administration. It will be the responsibility of the Operational ADOS and Program Managers to ensure all medications on MAR's are administered correctly and no discrepancies are noted. Training Specialist will train all Program Managers on the correct way to have MAR'S completed to ensure all medications on the MAR'S meet this regulation. The Medication Audit form has been revised to ensure proper oversight. This form will be submitted monthly by the 5th of each month to the Quality Department to be reviewed. See Attachment #3 Medication Audit Form. An Internal incident report will be submitted for any omissions of signatures so appropriate HR action can be taken. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. An Internal review of Medications was performed by the HR Director and another Certified Investigator to determine the root cause of these errors. All medication errors wiIl be entered into the EIM system. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. |
01/31/2019
| Implemented |
| 6400.165 | 6/9/18 Benztropine 1mg and Propranolol ER 120mg -- omission- on outing, didn't have meds. Errors not reported in EIM.
6/1/18-6/4/18 -- melatonin not administered -- pharmacy didn't deliver. Not reported
5/11/18- all 8am med omissions not reported in EIM.
4/23/18 -- omission of 120mg of Latuda not reported in EIM.
3/16, 3/17- Gavilax Powder 17 grams -- "no med in bottle of refill for 8am." not reported. | Documentation of medication errors and follow-up action taken shall be kept.
| Farm Lane staff including management will be retrained by 1/31/2019 on Medication Administration.It will be the responsibility of the Operational ADOS and Program Managers to ensure all medications on MAR's are administered correctly and no discrepancies are noted. Training Specialist will train all Program Managers on the correct way to have MAR'S completed to ensure all medications on the MAR'S meet this regulates The Medication Audit form has been revised to ensure proper oversight. This form will be submitted monthly by the 5th of each month to the Quality Department to be reviewed. See Attachment #3 Medication Audit Form. An Internal incident report will be submitted for any omissions so appropriate HR action can be taken. Any omissions of medication will be entered into the EIM System in the appropriate time frame. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. An Internal review of Medications was performed by the HR Director and another Certified Investigator to determine the root cause of these errors. All medication errors wilI be entered into the EIM system. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination. Any further delay of medications more than 24 hours will be reported to the Director of Services who will then immediately contact the pharmacy to resolve the issue. |
01/31/2019
| Implemented |
| 6400.167(b) | 6/26/18 Individual # 1 was prescribed Olanzapine 10mg 8pm 1 week then increase to 20mg at 8pm. -- 10mg given from 6/26-7/1/18. Not 1 week.--- 7/1 log indicated 10mg dose and 20mg dose administered. 7/26-7/30 not administered???
4/6/18-d/c gabapentin. -- not on log? - Log did not indicate this med was administered at all.
3/22/18-.. Gabapentin 100/0/100/0 for 1 week then D/C. 8am dose given 3/24-3/28. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Farm Lane staff including management will be retrained by 1/31/2019 on Medication Administration. It will be the responsibility of the Operational ADOS and Program Managers to ensure all medications on MAR's are administered correctly and no discrepancies are noted. Training Specialist will train all Program Managers on the correct way to have MAR'S completed to ensure all medications on the MAR'S meet this regulates The Medication Audit form has been revised to ensure proper oversight. This form will be submitted monthly by the 5th of each month to the Quality Department to be reviewed. See Attachment #3 Medication Audit Form. TLC has made the decision to restructure management responsibilities within the homes. Effective 2/1/2019 the Program Manager will only be responsible for 1 home. This change will ensure greater oversight and monitoring of day to day operations and supports for the individuals. This is a result of the increased expectations and enhanced regulations required to provide revolutionary supports to all individuals in Typical Life Corporation. An Internal review of Medications was performed by the HR Director and another Certified Investigator to determine the root cause of these errors. All medication errors wilI be entered into the EIM system. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination |
01/31/2019
| Implemented |
| 6400.181(e)(4) | Individual # 1's 6/29/18 assessment did not assess community supervision needs. | The assessment must include the following information: The individual's need for supervision.
| TLC understands that the assessments must not contain any content discrepancies and all information is consistent with other supervision information. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved. See Attachment #12 Email and Addendum to assessment sent to Support Coordinator. It will be the responsibility of all Clinical ADOS's to ensure the assessment reflect current information. This will also be monitored annually during the time the ISP is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the ISP. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination |
01/31/2019
| Implemented |
| 6400.181(e)(13)(vii) | Individual # 1/s 6/29/18 assessment did not assess hiss ability to safely his handle money. He is currently carrying up to $25 on his person. | 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.
| TLC understands that the assessment must not contain any content discrepancies and all information is consistent with other information. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved. See Attachment #12 Email and Addendum to assessment sent to Support Coordinator. It will be the responsibility of all Clinical ADOS's to ensure the assessment reflect current information. This will also be monitored annually during the time the assessment is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the ISP. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally, the Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure assessment's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination |
01/31/2019
| Implemented |
| 6400.186(a) | ISP reviews late 7/24/18-10/23/18 - completed on 11/6/18, 4/24/18-7/23/18 completed on 8/13/18. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | TLC understands that ensuring the ISP is reviewed at least every three months or more is essential to promote the individuals well being, health and safety. It will be the responsibility of all Clinical ADOS's to ensure the ISP reviews contain required time frames. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP reviews. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP reviews are properly monitored and contain required time frames. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination The ISP completed for the dates 7/24/18-10/23/18 is in compliance as it was completed within the 15 day time frame. Please see Attachment #13. |
01/31/2019
| Implemented |
| 6400.186(c)(1) | Period of 12/23/17 - 1/23/18 not covered in ISP reviews. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | TLC understands that ensuring the ISP is reviewed at least every three months or more is essential to promote the individuals well being, health and safety. It will be the responsibility of all Clinical ADOS's to ensure the ISP reviews contain required time frames. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP reviews. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP reviews are properly monitored and contain required time frames. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination |
01/31/2019
| Implemented |
| 6400.186(c)(2) | 1:1 supervision not reviewed in 11/6/18, 8/13/18, 4/27/18, 12/26/17 | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | TLC understands that the ISP must not contain any content discrepancies and all information is consistent with other medical/supervision information. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved. See Attachment #12 Email and Addendum to ISP sent to Support Coordinator. It will be the responsibility of all Clinical ADOS's to ensure the ISP reflect current information. This will also be monitored annually during the time the ISP is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the ISP. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure ISP's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. If any non compliance is found or records are not compliant, human resource progressive disciplinary action will be taken, up to and including termination |
01/31/2019
| Implemented |
| 6400.213(11) | Assessment indicated he can self administer a nasal spray. ISP indicated he cannot self administer this. Assessment:1:1 staffing M-F 7a-8:30a and 4p-10p.
Sat-Sun 1:1 10-6. 1:2 all other times. 10-15 minutes checks when in another area of home.
ISP: 10-15 minute checks up to 1 hour. 1:1 M-F 8am-10pm. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | TLC understands that the Assessment/ISP must not contain any content discrepancies and all information is consistent with other medical/supervision information. This is critical for the health and well being of people supported. This was an oversight by the Clinical ADOS which has now been resolved. See Attachment #12 Email and Addendum to Assessment sent to Support Coordinator. It will be the responsibility of all Clinical ADOS's to ensure Assessment/ISP reflect current information. This will also be monitored annually during the time the Assessment/ISP is updated and when there is any change to Behavior Support Plans, Restrictive Plans and critical revisions to the Assessment/ISP. This will be monitored by the Director of Services via the electronic health records. This citation and plan will be reviewed with all residential Associate Director of Services (ADOSs) on 1/3/2019. The meeting minutes will show the meeting has been completed. Clinical ADOS's will be trained on their responsibilities during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. Additionally the Quality Management team will monitor the Assessment/ISP and other information in the record for content discrepancies. This monitor will be created by the end of January 2019 and will be completed monthly to ensure Assessments/ISP's are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. TLC is in the process of hiring a Nurse for the Quality Department who will assist with monitoring the electronic health records to ensure regulations are being met. |
01/31/2019
| Implemented |