| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | The home provided notification to the local fire department of the address, location of bedrooms, and assistance needs in writing to the fire department on 4/1/2021. Individual #1 was admitted to the home on 5/1/2020 and requires verbal assistance with evacuation. | 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.
| Program specialist shall notify the local fire department upon initial admission, as needed and annually of exact location of all individuals in the home. Documentation will include exact location of individuals that need assistance in the event of an actual fire. If the needs of an individual in the home changes, the local fire department will be notified immediately of the change. Notification shall be kept current. Current notification to fire department will be submitted. |
04/18/2021
| Implemented |
| 6400.113(a) | Individual #1, date of admission 5/1/2020, received fire safety training on 5/4/2020. Individual #2, date of admission 5/4/2020, received fire safety training on 5/8/2020. Individual #3, date of admission 5/4/2020, received fire safety training on 5/8/2020. | 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. | Program specialist shall complete fire safety training for all individuals upon initial admission and annually thereafter. Fire safety will include evacuation procedure, general fire safety, responsibilities during the fire drill , the designated meeting place outside in case of a actual fire and smoking safety for those who smoke. Program special will instruct the individual on the fire safety training by having the individual participate in a mock fire drill. In the case of an individual who cannot participate, written documentation shall be kept. |
04/18/2021
| Implemented |
| 6400.141(a) | Individual #1, date of admission 5/1/2020, had an initial physical examination on 6/3/2020. Individual #2, date of admission 5/4/2020, had an initial physical examination on 10/16/2020. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program specialist will insure that all individuals have a physical examination within 12 months prior to admission and annually thereafter. Documentation of prior year physicals will be submitted if located. No individual will be admitted without proper documentation of physical going forward. |
04/18/2021
| Implemented |
| 6400.141(c)(3) | Individual #1, date of admission 5/1/2020, had the recommended Tetanus immunization in 5/2005 and again on 6/1/2020. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Program specialist will ensure immunizations for individuals over 18 are included in the physical. Immunization record of individual #1 will be obtained. Immunization record will be kept current. |
04/18/2021
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 5/1/2020, had an initial Tuberculin skin test completed 6/3/2020. Individual #2, date of admission 5/4/2020, had an initial Tuberculin skin test completed 10/19/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Program specialist shall insure that all individuals have TB skin testing by Mantoux method. TB test to be done upon initial admission with negative results every 2 years . TB test will be completed as part of the physical. If tested positive, and initial chest x-ray with results will be noted. |
04/18/2021
| Implemented |
| 6400.151(a) | Program Specialist #1, date of hire 2/10/2017, does not have a physical examination. Direct Service Worker #2, date of hire 11/14/2018, had an initial physical examination on 10/21/2020. Direct Service Worker #3, date of hire 3/9/2014, had an initial physical examination on 12/10/2020. Direct Service Worker #4, date of hire 11/11/2020, had an initial physical examination on 3/5/2021. Direct Service Worker #5, date of hire 7/14/2020, had an initial physical examination on 1/8/2021. | 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. | HHWC administration will ensure all staff has physical exams within 12 months prior to employment and every 2 years thereafter before working with any individual in the licensed home. No staff will be permitted to work directly with any individual until physical exam is obtained. Program specialist will not work directly with individuals until her physical on May 5, 2021 is complete. Documentation of physical will be submitted as part of POC |
04/18/2021
| Implemented |
| 6400.151(c)(2) | Program Specialist #1, date of hire 2/10/2017, does not have a Tuberculin Skin Test. Direct Service Worker #2, date of hire 11/14/2018, had an initial Tuberculin Skin Test completed 10/21/2020. Direct Service Worker #3, date of hire 3/9/2014, had an initial Tuberculin Skin Test completed 12/10/2020. Direct Service Worker #4, date of hire 11/11/2020, had an initial Tuberculin Skin Test completed 12/8/2020. Direct Service Worker #5, date of hire 7/14/2020, had an initial Tuberculin Skin Test completed 1/15/2021. | 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. | All staff will receive Tuberculin skin testing by Mantoux method with negative results every 2 years before working with an individual directly. This will be part of the physical. If TB skin test is positive, initila chest xray with results will be noted. Testing can be completed and certified in writing by a registered or licensed nurse instead of licensed physician, licensed physician assistant or certified nurse practioner. Program specialist will have documentation of received TB test as part of the POC |
04/18/2021
| Implemented |
| 6400.151(c)(3) | Direct Service Worker #2's physical examination, completed 10/21/2020, did not address communicable disease. Direct Service Worker #3's physical examination, completed 12/10/2020, did not address communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | New physical paperwork will include a signed statement the the person is free from communicable diseases. DSP #2 and #3 will submit paperwork that they are free form communicable disease and documentation submitted as part of the POC, Signed statement will include that the employee is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken the will prevent spread of disease to individuals. |
04/18/2021
| Implemented |
| 6400.181(a) | Individual #1, date of admission 5/1/2020, had an initial assessment completed 7/31/2020. Individual #3, date of admission 5/4/2020, did not have an initial assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Program specialist shall have assessments done ion time in accordance to reg 6400.181. Initial assessment will be 1 year prior or 60 days after admission to the residential home and updated annually thereafter. Annual assessments shall be admitted as POC. Initial assessment will include assessment of adaptive behavior and level of skills completed within 6 months prior to admission. |
04/18/2021
| Implemented |
| 6400.181(d) | The program specialist did not sign or date Individual #1's assessment completed 7/31/2020. The program specialist did not sign or date Individual #2's assessment completed 6/2/2020. | The program specialist shall sign and date the assessment. | HHWC will generate new assessment paperwork to include signature page for program specialist. Program specialist will sign and date individuals assessment completed 7/31/2020 for individual #1 and Individual #2 completed 6/2/2020 |
04/18/2021
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 7/31/2020, did not include information regarding the likes, dislikes, and interests of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | HHWC will generate assessment that will include likes, dislikes and the interest of the individual. Program specialist will complete assessment for each individual. Individual #1 completed assessment will be submitted as part of the POC |
04/18/2021
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 7/31/2020, did not include a lifetime medical history. Individual #2's assessment, completed 6/20/2020, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Program Specialist will ensure all individuals in the home will have a lifetime medical history as part of their record. Lifetime medical history will be part of the program specialist assessment. All individual's lifetime medical history will be completed and submitted as part of the POC, Medical history shall be updated as needed |
04/18/2021
| Implemented |
| 6400.46(a) | Program Specialist #1, who began working with individuals on 5/1/2020, had fire safety training on 7/19/2020. Direct Service Worker #2, who began working with individuals on 5/1/2020, had fire safety training on 7/19/2020. Direct Service Worker #3, who began working with individuals on 5/1/2020, had fire safety training on 7/19/2020. | 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. | HHWC administration will train all individuals in general fire safety, evacuation procedures and responsibilities during fire drills and designated meeting place outside of 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, use of fire extinguishers, smoke detectors and fire alarms and notification of the local fire department as soon as possible after fire is discovered. Fire safety training shall occur before working with individuals. Implemented immediately with all new employees. |
04/18/2021
| Implemented |
| 6400.46(d) | Direct Service Worker #2's, date of hire 11/14/2018, had training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation completed on 6/20/2020. Documentation of the prior training was not provided therefore compliance was unable to be measured. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | HHWC administration will ensure all employees working in the 6400 licensed home will have training within 6 months after the day of initial employment and annually thereafter by a certified trainer in first aide, Heimlich techniques and CPR. HHWC administration has scheduled first aide and cpr course for May 16, 2021 for all staff working in the home. |
04/18/2021
| Implemented |
| 6400.165(g) | Individual #1, date of admission 5/1/2020 has not had a review of medications prescribed to treat symptoms of a psychiatric illness. Individual #1 is prescribed Risperidone 0.5 mg for explosive disorder. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Program specialist will ensure review of psychiatric medication for psychiatric illness be reviewed by licensed physician at least every 3 months that includes reason for prescribing the medication, the need to continue the medication and the necessary dosage. Documentation of review will be provided as part of the POC upon completion by the physician. Appointment will be made for Individual #1 as POC . |
04/18/2021
| Implemented |
| 6400.169(a) | Program Specialist #1 administered Amlodipine Besylate 5 mg tab, by mouth nightly at 8:00 PM to Individual #3 on 3/22/2020, 3/27/2021, and 3/28/2020 without successfully completing the Department-approved medication administration course. Direct Service Worker #3 administered Amlodipine Besylate 5 mg tab, by mouth nightly at 8:00 PM to Individual #3 on 3/30/2020 and 3/31/2020 without successfully completing the Department-approved medication administration course. Direct Service Worker #5 administered Carbamide Peroxide Debrox, install 5 drops into both ears twice a day at 7:00 AM to Individual #3 on 3/27/2020 and 3/28/2020 without successfully completing the Department-approved medication administration course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Program specialist and all team members administering medication will not administer medication before completing approved medication administration course, including course renewal requirements may administer medications, injections, procedures and treatments as specified in 6400.162. Documentation of program specialist completion of required medication training by certified medication trainer will be submitted as POC. |
04/18/2021
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment completed 7/31/2020 to the individual plan team members for the individual plan meeting on 8/11/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist will provide the individual plan is updated and assessment provided to the ISP team members at least 30 days prior to a ISP meeting. |
04/18/2021
| Implemented |
| 6400.182(c) | Individual #2's individual support plan, last updated 1/21/2021 states that Individual #2 "is not at risk of ingesting any poisonous substances if unattended". The assessment completed 6/20/2020 for Individual #2 states that Individual #2 requires "total support to safely use or avoid poisonous materials". | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program specialist will insure individual #2 plan is updated in the ISP to include total support to safely use or avoid poisonous materials. The individual plan will be revised annually, upon initial development and revised when the individuals needs changed at current assessment. The ISP team will ensure that the individuals ISP is current and correct. |
04/18/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include information about race, hair color, eye color, nor identifying marks. Individual #2's record did not include information about race, hair color, eye color, nor identifying marks. Individual #3's record did not include information about race, hair color, eye color, nor identifying marks. | 213(1)ii - Each individual's record must include the following information: Personal information, including: (ii) Weight, height, race, hair color, eye color, and identifying marks. | HHWC administration will generate new paperwork to include weight, height, race, hair color, eye color and any identifying marks. Records will be maintained in each individuals record. Paperwork will be submitted as part of the POC. |
04/18/2021
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include information about religious affiliation. Individual #2's record did not include information about religious affiliation. Individual #3's record did not include information about religious affiliation. | 213(1)iv - Each individual's record must include the following information: Personal information, including: (iv) Religious Affiliation | HHWC administration will generate new paperwork. All individual records will include religious affiliation. Paperwork will be submittted as part of the POC. |
04/18/2021
| Implemented |