| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, date of admission 9/22/17, initially signed and dated a statement acknowledging receipt of the information on rights on 9/26/17. | 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. | A formal paperwork review following the intake meeting must occur prior to the transition of a new individual to the agency. Agency policy change will require that all prospective or transitioning participants complete a intake meeting within 10 days prior to admission. Following the meeting the documentation must be reviewed for accuracy. This policy retraining will occur to ensure that such efforts are made to obtain the proper documentation prior to the receipt of home and community based services. Program Specialist and Site Supervisors will be retrained in this area on 7/31/2018. [Immediately, the CEO shall develop and implement a tracking system to ensure all individuals are informed of the information on rights, timely. Upon admission and at least quarterly for 1 year, the CEO shall audit statement signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights and the aforementioned tracking system to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/31/2018
| Implemented |
| 6400.81(k)(6) | There was not a mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Per the history of behavior of the individual it is not recommended to have a mirror in the bedroom. Documentation will be obtained from the family which provides insight on Individual #1's needs, as well as Individual #1 to indicate having no need for a mirror in the bedroom at this time. All other major furnishings are made available to the participant. A mirror is present in the bathroom adjacent to the participants bedroom. If the participant indicates a present need for a mirror it will be purchased now, and used in the event the participant and or the family has a change in their current wishes. The document will be uploaded to the participants file by 7/13/2018 as this has been verbally agreed upon sine September of 2017. [Individual #1's assessment updated on 7/13/18 indicated that Individual #1 did not want a mirror. The family and the SC were notified of the update to the assessment. Immediately, and continuing at least quarterly, the Program specialist shall review all individuals assessments and ISPs to ensure accuracy including Individual #1's preference for the presence of a mirror in Individual #1's bedroom. (DPOC by AES,HSLS on 8/23/18)] |
07/13/2018
| Implemented |
| 6400.113(a) | Individual #1, date of admission 9/22/17, had initial fire safety training completed 9/26/17. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | Initial Fire Safety must be completed at the start of services with Pathways Community Living. The participant did not receive this training on the date of move in, only a fire drill was completed. Residential site supervisor, and Program Specialist have been made aware of the necessity of this compliance standard. Training on this topic was completed with the Program Specialist on 6/26/2018. Training for the residential supervisor was completed on 6/27/2018. [Immediately, the CEO shall develop and implement a tracking system to ensure all individuals are instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home, timely. Upon admission and at least quarterly for 1 year, the CEO shall audit all individuals' fire safety trainings and the aforementioned tracking system to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
06/27/2018
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination completed 4/21/17 and then again on 5/14/18. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Program Specialist will ensure that all participants are scheduled for a physical examination prior the expiration date. All participant physical examination information will be compiled in a electronic system to ensure that the date is not missed. A reminder alert for each physical examination and TB Test will begin 60 days prior to the expiration date to ensure proper time for scheduling. The Program Specialist will be responsible for the execution in the task, as well as informing the appropriate residential site supervisor of the requirement. Training on this matter was completed with site supervisors, and led by the Program Specialist on 6/27/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of individuals' current physical examinations to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)] |
06/27/2018
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 1/24/18, had a physical examination completed 1/31/18. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Human Resources Generalist will support the review of all employee physical information to ensure that all direct service workers have a signed documentation from a physician indicating that they have undergone a physical prior to working with individuals. A new hire checklist has been implemented and reviewed weekly to ensure that all agency standards are withheld. A monthly review of employee health records will occur to ensure staff are meeting the minimum requirements. To ensure that staff physicals and TB test are up-to-date, Human Resources Generalist will compile a list of staff that need physicals and TB tests. This will be done by doing a review of employee medical files. Human Resources Generalist was trained on this information regarding regulatory standards on 7/6/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of staff persons' physical examinations to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)] |
07/06/2018
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1, date of hire 1/24/18, had Tuberculin skin testing by Mantoux method with negative results completed 3/6/18. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Human Resources Generalist will support the review of all employee physical information to ensure that all direct service workers have a signed documentation from a physician indicating that they are free of communicable disease. A new hire checklist has been implemented and reviewed weekly to ensure that all agency standards are withheld. A monthly review of employee health records will occur to ensure staff are meeting the minimum requirements. To ensure that staff physicals and TB test are up-to-date, Human Resources Generalist will compile a list of staff that need physicals and TB tests. This will be done by doing a review of employee medical files. Human Resources Generalist was trained on this information regarding regulatory standards on 7/6/2018. [Immediately and continuing at least quarterly, the CEO shall audit the aforementioned tracking system and a 25% sample of staff persons' Tuberculin skin testing to ensure timely completion. (DPOC by AES,HSLS on 8/23/18)] |
07/06/2018
| Implemented |
| 6400.161(e) | Neosporin OTC Cream, Tylenol 500mg, and Diabetic Tussin DM Syrup were with Individual #1's medications and were reportedly discontinued. | Discontinued prescription medications shall be disposed of in a safe manner. | House Supervisors have been instructed to complete a weekly review of medication boxes to ensure appropriate medication is present for the participant. Medication administration recorders (MAR) are going to be crossed checked to the Medication blister packs and medication original labeled containers once a week by supervisors and the medication administration trainer. Also, during site inspections, the expiration dates of all medication will be checked. If any medication is expired it will be properly disposed of. A review of the medication will occur monthly by the Medication Trainer, with a report submitted to the Program Specialist based on findings. The Medication Trainer will be responsible for random checks of the medication boxes to be completed on a bi-weekly basis to improve quality control measures. The medication trainer was made aware of this procedural change as of 7/6/2018. Site Supervisors were made aware of these changes during a formal meeting on 6/27/2018. [On 7/30/18, the discontinued medications for Individual #1 were not in the home. Documentation of aforementioned medication audits shall be kept and reviewed by the CEO at least monthly to ensure all individual are administered medications as prescribed and documented as required and discontinued medications are disposed of in a safe manner. (DPOC by AES,HSLS on 8/23/18)] |
07/06/2018
| Implemented |
| 6400.167(b) | Clotrim/Beta Cream Diprop, apply topically to abdomen daily prescribed for Individual #1 was most recently administered 6/2/18. Ciclopirox Sol 8% prescribed for Individual #1 was most recently administered 5/30/18. On 6/7/18, these medications were not in the home and available for administration. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | House Supervisors have been instructed to complete a weekly review of medication boxes to ensure appropriate medication is present for the participant. Medication administration recorders (MAR) are going to be crossed checked to the Medication blister packs and medication original labeled containers once a week by supervisors and the medication administration trainer. Also, during site inspections, the expiration dates of all medication will be checked. If any medication is expired it will be properly disposed of. A review of the medication will occur monthly by the Medication Trainer, with a report submitted to the Program Specialist based on findings. The Medication Trainer will be responsible for random checks of the medication boxes to be completed on a bi-weekly basis to improve quality control measures. The medication trainer was made aware of this procedural change as of 7/6/2018. [On 7/30/18, the discontinued medication for Individual #1 were not in the home. Documentation of aforementioned medication audits shall be kept and reviewed by the CEO at least monthly to ensure all individual are administered medications as prescribed and documented as required and discontinued medications are disposed of in a safe manner. (DPOC by AES,HSLS on 8/23/18)] |
06/27/2018
| Implemented |
| 6400.168(d) | Direct Service #2's certification to administer medication expired on 5/12/18 and was not recertified until 5/29/18. Direct Service Worker #2 administered medications to Individual #1 from 5/13/18 and 5/23/18. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | All practicums need to be completed at least a week be prior to the expired date to prevent any medication administration compliance errors. Also all practicums need proper cover sheets attached to file. A procedural change will go into effect as of July 2018 indicating that the Medication Trainer must submit a report identifying the completion of each Annual Practicum on a monthly basis to the CEO. Retraining on this information was completed during supervision with the Medication Trainer during the week of 7//2018. [On 7/30/18 during the POC verification a Med/Mar review was conducted for Individual #1 and there was a medication that did not match the MAR. The medication Fluocinonide Ointment .05% had a label that indicated: Apply topically twice a day to abdominal rash. The Mar indicated Apply to affected area once every morning. The Mar indicated that the medication was being administered once per day. [Immediately and continuing at least monthly for 1 year, the CEO and a certified medication trainer shall audit all staff person medication administration training to ensure completion. All staff person not certified to administer medications shall not administer medications. Immediately, the CEO and the certified medication trainer shall develop and implement a tracking system to ensure all staff persons who administer medications have completed the initial and annual medication administration trainings and practicums as required. At least quarterly for 1 year the CEO shall audit the aforementioned tracking system. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/06/2018
| Implemented |
| 6400.181(f) | The program specialist provided Individual #1's assessment completed 10/3/17 to the SC and plan team members on 12/1/17 for an annual ISP meeting on 12/12/17. (Repeated Violation-6/21/17, et al) | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The identified error in sending the quarterly report to the Service Coordinator was based on the individual being in crisis. It is typical that all Residential Assessments are sent to the plan team in adequate within the specified timeframe it is due. All retraining efforts on this agency standard was discussed during supervision with the Program Specialist on 6/26/2018. [Individual #1's assessment completed 7/19/18 had been sent to plan team members on 7/28/18. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. Immediately, the CEO shall develop and implement a tracking system to ensure the program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting, timely. At least quarterly for 1 year, the CEO shall audit the tracking system and a 25% sample of correspondence documentation showing the program specialist has provided all individuals' assessments to the plan team members, timely. (DPOC by AES,HSLS on 8/23/18)] |
06/26/2018
| Implemented |
| 6400.186(b) | The program specialist did not date the ISP review completed 3/31/18 for Individual #1. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The ISP review was historically completed by the House Supervisor, and then submitted for approval by the Program Specialist. The document will be generated and approved by the Program Specialist; with the signature acknowledgment of the development of the ISP review. Any updates for the ISP have already been completed for this measure and will be entered accordingly to upcoming ISP Reviews effectively immediately. Retraining on this procedural change was discussed during supervision with the Program Specialist on 6/26/2018. [Individual #1's ISP review dated 3/31/18 was completed and signed by the program specialist on 7/13/18. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO shall audit a 25% sample of individual ISP reviews to ensure program specialist has completed the ISP reviews, timely. (DPOC by AES,HSLS on 8/23/18)] |
06/26/2018
| Implemented |
| 6400.186(d) | The program specialist provided Individual #1's ISP review documentation completed 12/31/17 to the SC and plan team members on 3/19/18. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The identified error in sending the quarterly report to the Service Coordinator was based on the individual being in crisis. It is typical that all Quarterly Reports are sent to the plan team in adequate within the specified timeframe it is due. All retraining efforts on this agency standard was discussed during supervision with the Program Specialist on 6/26/2018. A peer review of ISP reviews will occur monthly by the Program Coordinator to ensure proper standards. [Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) Documentation of the trainings shall be kept. Immediately, the CEO shall develop and implement a tracking system to ensure the program specialist shall provide the individuals ISP reviews to plan team members as required, timely. At least quarterly for 1 year, the CEO shall audit the tracking system and a 25% sample of correspondence documentation showing the program specialist has provided all individuals' ISP reviews to the plan team members as required, timely. (DPOC by AES,HSLS on 8/23/18)] |
06/27/2018
| Implemented |