| 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 8/3/20, 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/findings 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 |
| 6400.77(b) | At the time of inspection, the first aid kit was not equipped with tape. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A first aid kit and it's required items are designed to be able to respond to most first aid emergencies and protect the health and well-being of the supported persons. There was no tape in the first aid kit. There was not a procedure in place checking the contents of the first aid kit versus the regulatory list Tape was bought and placed in the first aid kit The Program Managers, and in their absence the Operational ADOS for each location will check the contents of their first aid kit and confirm through an MS Form the completeness of the materials in the first aid kit at the location they are responsible for leading. These documents will be available electronically through the Quality Assistant, who will on the 20th of each month ensure that each house has completed the check and identified the items are complete as per the regulation. The Quality Assistant will communicate via email to the ADOS and the Program Manager any deficiencies. |
02/19/2021
| Implemented |
| 6400.112(a) | There were no fire drills completed in 11/2020 or 12/2020. | An unannounced fire drill shall be held at least once a month. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. There was no documentation that the fire drills were conducted Documentation was not adequately maintained Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.112(c) | On the fire drill record for the fire drill completed on 8/10/20, no time was listed as to when the fire drill occurred. The fire drills completed from December 2019 through March 2020 do not have the actual date the fire drills were completed. The fire drill log provided does not address if problems were encountered during the fire drill or if the smoke detector was operable. | 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. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. There was no documentation that the fire drills were conducted Documentation was not adequately maintained Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.112(d) | The evacuation time for the following dates was changed on the fire drill record, making it unclear as to what the accurate evacuation time was: 4/19/20, 7/9/20, and 8/10/20. | 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. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. The fire drill record was completed inaccurately The change in leadership turnover resulted in an oversight of this requirement. Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Implemented |
| 6400.112(e) | From December 2019 through December 2020, there were no sleep drills completed. | A fire drill shall be held during sleeping hours at least every 6 months. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. Sleep fire drills were not conducted for the 12/2019-12/2020 time period The change in leadership turnover resulted in an oversight of this requirement. Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Implemented |
| 6400.112(h) | The fire drill records do not indicate if all individuals made it to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. Individuals did not make it to the designated location Various staff and supervisor changes led to inconsistencies within quality of training received and comprehension of regulations Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.112(i) | The fire drill log does not address if the smoke detector was set off. | A fire alarm or smoke detector shall be set off during each fire drill. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. The smoke detector was not set off to initiate the fire Various staff and supervisor changes led to inconsistencies within quality of training received and comprehension of regulations Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Implemented |
| 6400.32(r) | Individuals #1, 2, and 3 were not offered the option to have a lock on their bedroom doors. | An individual has the right to lock the individual's bedroom door. | Individuals have the right to have locks on their bedroom doors to protect their belongings. Individuals were not offered the opportunity to have locks placed on their bedroom doors. The choice to have a lock on a bedroom door was not discussed during team meetings. The residential provider will contact the individual's team to schedule a meeting to discuss the person's choice for a lock on the bedroom door. If the person wants a lock, the residential provider will ensure a lock is installed. The meetings will take place by 4/30/2021 and be scheduled by the Clinical ADOS before March 10 During the annual ISP meeting, or when the person requests, the residential provider will ensure the subject of securing the bedroom is discussed. The Directors of Residential will monitor the completion of this task during monthly supervisions with the residential Clinical and Operational Associate Directors. |
03/12/2021
| Implemented |