Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.31(b) | Individual # 1 signed Resident rights form 0n 12/06/16. No documentation of Rights information in 2017. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | It was found that the individuals rights were not completed for the year 2017. The clinical ados for this program did not complete this documentation requirement and an adequate monitoring tool for this was not established. Individual # 1's guardian has signed Resident Rights on 11/28/2018. See Attachment #10. All Clinical ADOS's are responsible to ensure Resident Rights are reviewed and signed annually each January. The signed Residents Rights and signature form will be scanned into AWARDS under the individual's filing cabinet by the ClinIcal ADOS. To monitor and ensure the individual rights are completed annually, training for the clinical ados will occur as part of their new hire orientation. This will also be a part of their management training, referencing the Practice and Guideline, to be completed by the DIrector of Service. The Practice and Guideline will be established to ensure resident's rights are completed per regulations and that resident rights are properly honored The Quality Department will review the individual records as part of pre-licensing to monitor for compliance. The Quality Department will ensure that Resident Rights are reviewed and signed within 3 days following any new admission and each January 20th to ensure completion. Additionally, the records will be randomly reviewed by the Director of Service to monitor for compliance. The Rights signature form will be scanned into AWARDS under the individual's filing cabinet by the ClinIcal ADOS. In addition members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. |
01/31/2019
| Implemented |
6400.31(c) | Individual # 1 was not encouraged to exercise his/her rights, including right to privacy in bathroom and bedroom. | Each individual shall be encouraged to exercise his rights. | The Behavior Support Plan was revised to include privacy in the bathroom and bedroom. This plan was reviewed with the family. The BCBA discussed with the family, the Individual #1's right to privacy in the bathroom and bedroom and the importance of that right for Individual #1. See Attachment #11 Behavior Support Plan. The Director of Services will work the treatment team to compile and complete the biographical timeline for Individual #1. The Board Certified Behavior Analyst will continue to train the program team on ensuring individual #1's rights are complied with as per the regulation. Additionally, the BCBA will continue to work with the guardians to comply with these rights and the importance of promoting the individuals growth and independence. In addition members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. |
02/01/2019
| Implemented |
6400.33(j) | Individual # 1's assessment stated that he needs support in registering to vote. Staff (PS) informed that there is no documentation of registering or encouraging Individual # 1 to vote. | An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections. | It was found that the individual was not be supported in his right to vote. The clinical ados will work with the program team and guardian to ensure rights are adhered to, this will be done in program team meetings and annual recertification of safe crisis management. This will be documented through meeting minutes, training agendas and collateral notes when discussed with the guardian. Additionally, any rights that any individual needs supports for will be documented in the ISP and Assessment with a plan to support that right if needed. When a legal guardian is involved this will be reviewed with the legal guardian. To monitor and ensure the individual rights are completed annually, training for the clinical ados will occur as part of their new hire orientation. ADOS Orientation Checklist. Part of their management training will include training on the Practice and Guideline, to be completed by the Director of Service. The Practice and Guideline will be established to ensure resident's rights are completed per regulations and that resident rights are properly honored. Members of the quality management team will randomly check residences to ensure the residences rights are being honored. This will be part of a quality management initiative modeled upon the MyODP quality training module. Meetings to begin this process will begin on 12/20/2018 and will continue each week. If the Individual's Rights are not completed and rights are not being honored as per the Practice and Guideline, human resource progressive disciplinary action will be taken, up to and including termination. |
01/31/2019
| Implemented |
6400.110(b) | Smoke detector by bedroom was not functional during walk through. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | This noncompliance was resolved immediately upon notification of the smoke detector being non functional during the licensing walk through.The smoke detector is checked at a minimum of each month during the fire safety monitoring for the program. At the last monitor, it was working. At this home, the smoke detector is checked routinely as the individual will break the smoke detector on purpose. It is recessed in the ceiling to reduce the destruction but does still occur. This particular home has smoke detectors readily available to them for replacement. This noncompliance was resolved on 11/20/2018. It will also be the responsibility of staff at this particular home to check smoke detectors on a daily basis due to the destructive behavior of the individual that resides within the home. See Attachment 110b. 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. If at any time a smoke detector is not readily available for replacement the maintenance department will be notified 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 compliance's are resolved on a timely basis. |
01/31/2019
| Implemented |
6400.141(a) | Individual # 1 had physical on 08/23/17 and not again until 10/10/18 | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 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. Additionally, all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. 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 ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. 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. |
01/31/2019
| Implemented |
6400.141(c)(1) | No documentation that Physician reviewed medical history on 10/10/18 physical | The physical examination shall include: A review of previous medical history. | 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. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. 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 ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. 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. |
01/31/2019
| Implemented |
6400.141(c)(4) | Individual # 1 did not receive Vision or Hearing Screening during 10/10/18 physical. "Unable to assess", "Normal by observation" on 08/23/17 physical. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 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. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. 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 ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. 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. |
01/31/2019
| Implemented |
6400.141(c)(14) | Information pertinent to diagnosis in case of emergency blank on 10/10/18 physical | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 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. Additionally all Associate Director of Services and Program Managers (PMs) will be trained during the Management Orientation between January and April 2019. The management orientation will be an ongoing initiative for all management staff. 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 ISPs are properly monitored. This type of oversight will be monitored very carefully through the use of our electronic health record. The Physical for Individual #1 was returned to PCP to be completed in its entirety. See Attachment #9. A Rights Violation Investigation EIM# 8469882 was completed and Confirmed in September 2018. 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. |
01/31/2019
| Implemented |
6400.183(4) | ISP Last updated 09/05/18 does not include plans for reduction of intensive staffing supports for targeted behaviors | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | TLC understands that the ISP must include plans for reduction of intensive staffing supports for targeted behaviors. 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.On Thursday December 6th, 2018 individual number #1's ISP was updated to include " reduction of intensive staffing supports for targeted behaviors" Please see attachment #8.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 |
6400.186(a) | ISP reviews not held every three months. Dates of reviews 11/25/17, 03/15/18, 06/05/18, 09/06/18 | 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 |
01/31/2019
| Implemented |
6400.186(b) | ISP reviews dated 06/05/18 and 03/15/18 are not signed by PS. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | TLC understands that ensuring the ISP Reviews are reviewed and signed upon completion. It will be the responsibility of all Clinical ADOS's to ensure the ISP reviews are reviewed and signed. 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 to ensure they are signed upon completion. 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 signatures. 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 |
6400.195(e)(6) | Individual # 1's Restrictive Plan does not include amount of time restrictive procedures may be applied. "If restraint occurs, it should only last as long as necessary and should be ended immediately as soon as Individual # 1 is calm." | The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter.
| Proper monitoring and oversight was not provided to ensure content discrepancies do not occur. Individual # 1's Restrictive Plan now includes amount of time restrictive procedures may be applied. The Treatment and Ethics Committee will ensure that this regulation is met during all reviews of Restrictive Plans. See Attachment #7 revised Restrictive Plan It will initially be the responsibility of all Clinical ADOS's to ensure Restrictive Plan's reflect the amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. This will also be monitored during the time The Treatment and Ethics Committee meets to review the Restrictive Plan's. 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 Restrictive Plan in the record for content discrepancies. Typical Life has recently hired a behavioral support person who will be part of the Treatment and Ethics Committee to assist with ensuring all regulations are met when creating a Restrictive Plan. The behavioral support person will create a monitor by the end of January 2019 ensuring Restrictive Plans are properly written. 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 |
6400.217 | No signed releases contained in record. Ptogram Specialist reported that Parents will sign this afternoon 11/14/18. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Signed releases were completed on 11/21/2018. Release of Information forms will be reviewed and completed each January and July, upon admission and upon any new services being implemented. A Practice and Guideline will be completed outlining this requirement and the expectations and responsibilities of the Clinical ADOS. This will also be part of the ADOS Orientation checklist that all current and future ADOS's will sign off on stating they understand this regulation. This will be completed by the Clinical ADOS and monitored by the Director of Services. See Attachment #6 Signed Releases. Additionally, the Quality Management team will monitor the Release of Information forms. This monitor will be created by the end of January 2019 and will be completed monthly to ensure Release of Information forms are present.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 |