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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeat from inspection dated 1/11/21) The self-assessment completed for this home was not dated; not able to to verify if the self-assessment was completed in the correct time frame. | 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. | This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly on 2/22/22. Quality department will monitor for completion. |
02/22/2022
| Implemented |
| 6400.66 | At the time of the inspection, there was no light in the front bedroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance request was placed to install light. · This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022.
We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). |
02/22/2022
| Implemented |
| 6400.70 | At the time of the inspection, there was no telephone at the home. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Telephone has been placed in the home. · This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022.
We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). |
02/22/2022
| Implemented |
| 6400.71 | At the time of the inspection, there were no emergency numbers posted in the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Telephone has been placed in the home and emergency numbers have been added to the telephone. · This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022.
We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). |
02/22/2022
| Implemented |
| 6400.77(a) | At the time of the inspection, there was no first aid kit. | A home shall have a first aid kit. | First Aid kit has been purchased and placed in the home. · This occurred due to TLC currently having a form on SharePoint that staff complete following a physical site check. Quality department will utilize the physical site check list form which was updated on 1/20/2022 to determine which homes have not completed the physical site check list. The quality department will send an email to Program Manager, and DORS to inform them of which homes need to be completed. Staff will be retrained Program Specialists will be trained on Physical Site Requirements beginning on 02/16/2022, all other staff will be trained during the staff meeting on 02/22/2022.
We developed a schedule for staff meetings that will be held monthly beginning on February 22, 2022, as well as Program Specialist Trainings that will be held weekly beginning February 16, 2022. The purpose of the Staff Meetings are to communicate important changes to all staff, develop consistency, and train all staff on regulations, practices, and guidelines. All staff will be retrained on Fire Safety, Rights of the Individual, and Medication Error Reporting during the meeting. The purpose of the Program Specialist Trainings is to ensure that all Program Specialists are aware of, following, and in compliance with the regulations. During the first Program Specialist training, job responsibilities, medication administration & errors, physical site checklists/ home monitoring schedules, medical appointments, assessments, fire safety, individual rights, releases of information, and individual records will be addressed. Moving forward, Program Specialist training will focus on things that the Quality Department identifies as areas of concern (QD will be utilizing the Home Monitoring Tool, Physical Site Checklist and Fire Monitoring Tool to determine where the areas of need are). |
02/22/2022
| Implemented |
| 6400.104 | (Repeat from inspection dated 1/11/21) Individuals haven't resided in the home since August 2021. During the first day of the January 3, 2022 annual inspection, the home sent a letter to the local fire department notifying them that the home is now vacant. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Director of Residential will have Program Specialists send out Fire Letters for all homes to reflect current individuals in the homes, the layouts, and locations of the individuals 02/28/2022 |
02/28/2022
| Not Implemented |
| 6400.112(a) | (Repeat from inspections dated: 1/11/21, 5/10/21, and 10/12/21) A fire drill was not held in February or June 2021. The fire drill record for February states the individual was not at home during the time the staff decided to hold the fire drill and there are no records of a fire drill being conducted in June 2021. | An unannounced fire drill shall be held at least once a month. | Training on Fire Drill Requirements have been provided to all staff. |
02/28/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Staff # 7 was trained in Fire Safety on 03/15/17 and not again until 07/16/18 | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The quality management team, which includes the Training Department, will track all agency training's and coach staff to monitor their training needs. Typical Life utilizes the College of Direct Supports with tracking all training's including state mandated training's. The Training Specialist will be responsible to run a report in the College of Direct Supports prior to the end of each of month for all training's. The Training Specialist will be responsible to notify any staff of any training's that need to be completed. If at any time any staff member is out of compliance for any training's appropriate HR action will be taken. This will include suspension without pay and any additional appropriate HR action deemed necessary, until required training's are completed. As a result they will not be out of compliance with any training requirement. They will have to receive the training prior to working again with any individual. Policy and procedure 0500-054 will be revised to support this and all staff are required to acknowledge this within 30 days of the policy and procedure being promulgated. The policy and procedure will be reviewed with all staff at the next All Staff meetings on January 9, 16, and 23. Attendance of those meetings will be recorded as part of our payroll system. All Policies are reviewed during the new hire orientation. A Quality Meeting will be held every Monday from 9:30am-11:30am to review all aspects of the Quality department to ensure all regulations are met. |
01/31/2019
| Implemented |
| 6400.46(h) | Staff # 7 was trained in FA/CPR on 06/24/17 and not again until 07/24/18 | 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. | The quality management team, which includes the Training Department will track all agency training's and coach staff to monitor their training needs. Typical Life utilizes the College of Direct Supports with tracking all training's including state mandated training's. The Training Specialist will be responsible to run a report in the College of Direct Supports prior to the end of each of month for all training's. The Training Specialist will be responsible to notify any staff of any training's that need to be completed. If at any time any staff member is out of compliance for any training's appropriate HR action will be taken. This will include suspension without pay and any additional appropriate HR action deemed necessary, until required training's are completed. As a result they will not be out of compliance with any training requirement. They will have to receive the training prior to working again with any individual. Policy and procedure 0500-054 will be revised to support this and all staff are required to acknowledge this within 30 days of the policy and procedure being promulgated. The policy and procedure will be reviewed with all staff at the next All Staff meetings on January 9, 16, and 23. Attendance of those meetings will be recorded as part of our payroll system. All Policies are reviewed during the new hire orientation. A Quality Meeting will be held every Monday from 9:30am-11:30am to review all aspects of the Quality department to ensure all regulations are met. |
01/31/2019
| Implemented |
| 6400.110(a) | No fire extinguisher or smoke detector in attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | A contracted maintenance worker removed the screws that were sealing off the attic access to make repairs. Upon his departure, the attic was not re-sealed and the physical site walk through by the Program Manager did not catch the issue. The Director of Property has instructed the Maintenance Department to ensure all properties meet the State Regulations after any contractor has completed work within any home. Additionally, following any work performed by a contractor the Program Manager/Operational ADOS will be responsible for completing a physical site review to ensure all regulations are met. This noncompliance was resolved on 11/20/2018. 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 items needed attention 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 compliance's are resolved on a timely basis. |
01/31/2019
| Implemented |
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