Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234775 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 03/08/23 had an evacuation time of 3 minutes and 4 seconds. The fire drill conducted on 08/13/23 had an evacuation time of 2 minutes and 36 seconds. There is no extended evacuation time specified in writing within the past year by a fire safety expert. 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. TRIAD BEHAVIOR SUPPORT SERVICES POC RE: Plan of Correction for Fire Drill Evacuation Time and Documentation of Training Email notification sent to staff on 11/20/2023 for immediate correction and then a detailed training on 11/20/2023 was also conducted. 2182 E Maiden Violation 6400.112(d): The fire drill conducted on 03/08/23 had an evacuation time of 3 minutes and 4 seconds. The fire drill conducted on 08/13/23 had an evacuation time of 2 minutes and 36 seconds. There is no extended evacuation time specified in writing within the past year by a fire safety expert. Please read and sign by your name on the attached training form. How to time a fire drill Timing the Drill The fire drill time begins when the alarm is sounded and ends when the last individual enters the fire safe area(s) or exits the outside door. The best way to record this is by using two stopwatches, as follows: 1. When the alarm sounds, start both stopwatches. 2. When you believe that all individuals have exited the building or arrived in a fire-safe area, stop one of the stopwatches. 3. Check the home to ensure that all individuals have evacuated. If you discover that one or more individuals have not evacuated, assist the individual out of the building or to a fire-safe area. Once all of the individuals have been evacuated, stop the second stopwatch. ¿ If when checking the home you discover that all individuals have evacuated, the time recorded by the first stopwatch is the official fire drill time. ¿ If one or more individuals did not evacuate as described in #2 above, the time recorded by the second stopwatch is the official fire drill time. In the latter case, it is recommended that both times be recorded on the fire drill record required at 6400.112(c) to demonstrate that most individuals were able to evacuate in time, since the scope of the problem is related to developing an acceptable plan of correction. 6400.112(d) (a) An unannounced fire drill shall be held at least once a month. (b) Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. (c) 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. (d) 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. (e) A fire drill shall be held during sleeping hours at least every 6 months. (f) Alternate exit routes shall be used during fire drills. (g) Fire drills shall be held on different days of the week and at different times of the day and night. (h) Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. (i) A fire alarm or smoke detector shall be set off during each fire drill. It is important to stop timing the drill once the individual has safely exited the building/home. To prevent this from reoccurring Triad CEO has immediately retrained the Program Director and Program Specialist and the Program Specialist has retrained all direct care residential staff at all residential homes specifically on careful and accurate timing of fire drill evacuations. Additionally, the program specialist is tasked with a plan to check and sign off on the fire drill records monthly and then once again during the quarterly progress report time. Every three months all required forms will be reviewed again for accuracy by all management personnel. Both the staff and the program specialist have roles and responsibilities to ensure accurate form completion. During the fire drill the DSP is responsible for ensuring that the individual safely evacuates in a timely manner of under 2 ½ minutes and accurately documenting all fire drill related matters on the fire drill form. The DSP will immediately notify the Program Specialist if any concerns arise during the fire drill. The Program Specialist will review the fire drill form monthly and then again during the quarterly review. Triad Behavior Support Services Training Form Plan Of Correction 11/20/2023 Heather Betts / CEO / Trainer ______________________________ Gary Betts / Program Director / Trainer ________________________ Jacob Hanning Program Specialist ____________________________ STAFF PRINT NAME STAFF SIGNATURE 11/20/2023 Implemented
6400.165(g)Individual #1's reviews by a licensed physician for medication prescribed to treat symptoms of a psychiatric illness completed on 12/15/22, 01/09/23, 02/06/23, 03/06/23, 04/03/23, 05/02/23, 05/30/23, 06/29/23, 07/24/23, 08/14/23, 09/07/23, 09/28/23, 10/19/23, and 11/09/23, did not include the name of the medication Invega Sustenna, the reason for prescribing the medication or the necessary dosage.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.TRIAD BEHAVIOR SUPPORT SERVICES POC RE: Plan of Correction for Medication Summary Form and Documentation of Training Email notification sent to staff on 11/20/2023 for immediate correction and then a detailed training on 11/20/2023 was also conducted. 2182 E Maiden Violation Individual #1's reviews by a licensed physician for medication prescribed to treat symptoms of a psychiatric illness completed on 12/15/22, 01/09/23, 02/06/23, 03/06/23, 04/03/23, 05/02/23, 05/30/23, 06/29/23, 07/24/23, 08/14/23, 09/07/23, 09/28/23, 10/19/23, and 11/09/23, did not include the name of the medication Invega Sustenna, the reason for prescribing the medication or the necessary dosage. Please read and sign by your name on the attached training form. All staff have been immediately retrained on ¿How to complete the medical summary form and medication documentation procedures¿. It is important that all medications (regardless of who is administering the medication) be appropriately and accurately recorded and documented on all paperwork that outlines medications for each individual. To prevent this from reoccurring Triad CEO has immediately retrained the Program Director and Program Specialist and the Program Specialist has retrained all direct care residential staff at all residential homes specifically on current and accurate medication documentation. Additionally, the program specialist and medication administrator is tasked with a plan to check and sign off on the Medication Administration Records monthly and then once again during the quarterly progress report time. Every month all required forms will be reviewed again for accuracy by management personnel. Both the staff and the program specialist have roles and responsibilities to ensure accurate form completion. During a medical appointment the DSP is responsible for ensuring that the medical forms have accurate and current information prior to the appointment. This is extremely important so that all medical personnel are aware of any and all medications that are currently being prescribed. All medications will be listed on all paperwork regardless of who administers the medication. Staff are tasked with ensuring the name of the medication, the reason for prescribing the medication, and the dosage of the medication is accurate. The DSP will immediately notify the Program Specialist if any concerns arise as it relates to medication documentation. If any changes are made regarding any and all medication, then this information is immediately updated on all paperwork. The Program Specialist will review the medical summary forms monthly and then again during the quarterly review. The Program Specialist will cross-reference all medical appointment summary forms to ensure that all prescribed medications are current and accurate. Triad Behavior Support Services Training Form Plan Of Correction 11/20/2023 Heather Betts / CEO / Trainer ______________________________ Gary Betts / Program Director / Trainer ________________________ Jacob Hanning Program Specialist ____________________________ STAFF PRINT NAME STAFF SIGNATURE 11/20/2023 Implemented
SIN-00215321 Renewal 11/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, dated 9/21/2022, did not address medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 6400.141(c)(14)- (c) The physical examination shall include: (14) Medical information pertinent to diagnosis and treatment in case of an emergency. This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans, ensures that individuals¿ medical needs will be met, and that proper care is provided in the event of an emergency. The physical dated 9/21/2022 did not address 14) Medical information pertinent to diagnosis and treatment in case of an emergency (blank space). This violation was a result of human error / lack of attention to detail. On November 25 2022 residential leads were notified to contact the PCP to correct the blank space. Staff are required to return the form to the PCP for completion by December 9, 2022. Program Specialist will then review the document again to ensure the blank space has been completed by the PCP. [Documentation that Individual #1 physical examination, dated 9/21/22, was returned to the medical provider for completion of the individual's medical information pertinent to diagnosis and treatment on 11/28/22 was received on 1/12/23 and reviewed 1/12/23. Documentation of training related to medical appointment documentation for Program Specialist and Direct Service Workers, dated 12/15/22, was received on 1/12/23 and reviewed 1/12/23. DPOC by HDKP, HSLS, on 1/12/23]. 11/30/2022 Implemented
SIN-00197211 Renewal 12/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's December 2021 medication administration record did not include diagnosis or purpose for the following medications: Azelastine HCL Nasal Spray, Benzoyl Peroxide 5% wash, Divalproex Sod Er 500mg tablet, Escitalopram 20mg tablet, Fluticasone Prop 50Mcgs, Lithium carbonate Er 450mg tablet, Loratadine 10mg tablet, Tamsulosin HCL 0.4mg cap, and Tretinoin 0.05% Cream.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.12/1/2021 (date of inspection) the MAR for Individual #1 did not list the purpose of the medication. The diagnosis was on the MAR, the purpose was omitted. This violation was due to an oversight and misinterpretation issue. The regulation from 6400.166(a)(11) stated ¿Diagnosis or purpose for the medication, including pro re nata¿. Triad¿s interpretation was the MAR needed to have the Diagnosis OR purpose but not both. Program Specialist immediately on 12/1/2021 notified Triad Medication Administrator Trainer of the omission of the purpose of the medication. Medication Administrator immediately on 12/1/2021 corrected the MAR to include purpose. Per technical assistance, Program Specialist and Triad Medication Trainer updated the MAR and notified the pharmacy in order to update all medication records. 12/1/2021 Medication Administrator updated MAR to include purpose of medication. The steps Program Specialist took was on 12/1/2021 notify the Medication Admin Trainer at Triad to notify that the MAR would need a ¿purpose of medication¿ listed on the MAR. The pharmacy was notified on 12/1/2021 that a purpose of medication needed added to the MAR. 12/1/2021 The Medication Administrator Trainer reviewed the training materials from the Med Admin Trainer coursework to gather information on a plan of correction. 12/20/2021 Implemented
SIN-00179980 Renewal 12/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(10)Individual #1's physical examination completed 9/10/2020 does not address precautions communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Triad will utilize CEO, Office Manager, and Program Specialist to oversee internal spreadsheets to track and monitor compliance standards. Compliance will be measured by following 6400.141 Upon completion of individual physical exam, the staff present with the individual will line by line review the physical examination form to ensure all boxes are checked and that the form is completed, signed, and dated by a licensed physician, CNP, or licensed PA. The individual and the staff may leave the site location only once the entire document is reviewed and completed in its entirety. Once at home/residence the staff will scan and send (email) document immediately to program specialist, office manager, and CEO. The program specialist, office manager, and CEO will again review the document to ensure all boxes are checked and document is complete in its entirety. If there is any discrepancy then the physicians office will be notified by all parties for immediate attention and correction. Once received, we will review the document again. If completed, we will file the document per office protocol.[On 12/30/20, the CEO informed the Department that Individual #1's physical examination was updated to include missing information. Prior to staff person supporting individuals in completing physical examinations and/or reviewing documentation, the CEO or designee shall educate staff on the requirements of physical examinations and/or reviewing documentation to ensure physical examinations include all required information and all health services are arranged and provided to ensure the health of all individuals. Documentation of trainings and all audits of physical examinations shall be kept. (DPOC by AES,HSLS on 12/30/20)] 12/15/2020 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 9/10/2020 does not include an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Triad will utilize CEO, Office Manager, and Program Specialist to oversee internal spreadsheets to track and monitor compliance standards. Compliance will be measured by following 6400.141 Upon completion of individual physical exam, the staff present with the individual will line by line review the physical examination form to ensure all boxes are checked and that the form is completed, signed, and dated by a licensed physician, CNP, or licensed PA. The individual and the staff may leave the site location only once the entire document is reviewed and completed in its entirety (including assessment and recommendations). Once at home/residence the staff will scan and send (email) document immediately to program specialist, office manager, and CEO. The program specialist, office manager, and CEO will again review the document to ensure all boxes are checked and document is complete in its entirety. If there is any discrepancy then the physicians office will be notified by all parties for immediate attention and correction. Once received, we will review the document again. If completed, we will file the document per office protocol.[On 12/30/20, the CEO informed the Department that Individual #1's physical examination was updated to include missing information. Prior to staff person supporting individuals in completing physical examinations and/or reviewing documentation, the CEO or designee shall educate staff on the requirements of physical examinations and/or reviewing documentation to ensure physical examinations include all required information and all health services are arranged and provided to ensure the health of all individuals. Documentation of trainings and all audits of physical examinations shall be kept. (DPOC by AES,HSLS on 12/30/20)] 12/15/2020 Implemented
6400.151(b)Program Specialist #1's physical examination, completed dated 9/3/20 was not signed and dated by a licensed physician, certified nurse practitioner, or physician assistant The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The physical exam that was completed on 9/3/2020 was electronically signed and dated by a physician. Triad will request that the medical doctor office use handwritten signatures moving forward. Triad will utilize CEO, Office Manager, and Program Specialist to oversee internal spreadsheets to track and monitor compliance standards. Compliance will be measured by following 6400.151 Upon completion of staff physical exam, the staff present will line by line review the physical examination form to ensure all boxes are checked and that the form is completed, signed, and dated by a licensed physician, CNP, or licensed PA. The staff may leave the site location only once the entire document is reviewed and completed in its entirety. Once at home/residence the staff will scan and send (email) document immediately to program specialist, office manager, and CEO. The program specialist, office manager, and CEO will again review the document to ensure all boxes are checked and document is complete in its entirety. A third page was added to Triad internal staff physical exam to include a space for the clinician performing the exam/TB read to identify their credentials. If there is any discrepancy then the physicians office will be notified by all parties for immediate attention and correction. Once received, we will review the document again. If completed, we will file the document per office protocol. 12/15/2020 Implemented
6400.151(c)(2)Program Specialist #1's Tuberculin testing completed 9/5/20 was not 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. 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. The TB test was administered on 9/3/2020 was electronically signed and dated by a physician office on (read date) 9/5/2020. Triad will request that the medical doctor office use handwritten signatures moving forward as well as adding a line for the clinician to handwrite credentials. Triad will utilize CEO, Office Manager, and Program Specialist to oversee internal spreadsheets to track and monitor compliance standards. Compliance will be measured by following 6400.151 Upon completion of staff physical exam, the staff present will line by line review the physical examination form to ensure all boxes are checked and that the form is completed, (handwritten) signed, and (handwritten) dated by a licensed physician, CNP, or licensed PA. The staff may leave the site location only once the entire document is reviewed and completed in its entirety. Once at home/residence the staff will scan and send (email) document immediately to program specialist, office manager, and CEO. The program specialist, office manager, and CEO will again review the document to ensure all boxes are checked and document is complete in its entirety. A third page was added to Triad internal staff physical exam to include a space for the clinician performing the exam/TB read to identify their credentials. If there is any discrepancy then the physicians office will be notified by all parties for immediate attention and correction. Once received, we will review the document again. If completed, we will file the document per office protocol. All staff were retrained on form completion policy and procedures.[Immediately, prior to hire and upon completion, the CEO or designee educated in the requirements of employee physical examination shall audit all physical examination documentation to ensure completion with required information including completed Tuberculin testing to ensure the health and safety of the individuals with whom staff persons have direct contact or who prepares and serves food. Documentation of audits of physical examinations shall be kept. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
6400.167(a)(1)Azelastine Hcl Nasal Spray, use 2 Sprays into each nostril twice daily, prescribed to Individual #1 was only administered once a day in November 2020.Medication errors include the following: Failure to administer a medication.Insurance company changed dosage without informing team members. Triad management spoke with doctors office, insurance company, and pharmacy to identify a plan of correction. All staff were retrained on reading and comparing medication prescription labels with MARs. Program Specialist worked directly with staff in the home to review how to read prescription, how to compare prescription with prescription label, how to compare all documentation with the MARs. In the event that a discrepancy occurs, the direct care staff (or anyone dispensing medications) will immediately call the program specialist to verify and proceed with next steps. Immediate attention and resolution should occur within the same day but no more than 24 hours after identification of discrepancy. An incident report was filed and all staff were retrained within 12 hours of this violation. [Immediately and at least monthly and after medical appointments, a designated staff person who is certified to administer medications shall audit all individuals' current medication administration record, physician's orders, and medications to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/29/20)] 12/15/2020 Implemented
SIN-00162509 Renewal 08/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment for the home on 8/1/19. The agency's certificate of compliance expiration date was 9/14/2019.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. Self-assessment CEO is responsible for maintaining and updating the self-assessment for the agency. CEO should review and update as needed as physical changes occur. At least 90 days prior to the certificate of compliance expiration date the CEO will complete the self-assessment. CEO included the self-assessment date on our agency tracking spreadsheet so that the format will change colors as the date approaches. The CEO will track the expiration date on the spreadsheet. The CEO will then use that date as the target date minus 90 days. CEO will review dates to ensure that all dates are within compliance on at least a monthly basis. Internal spreadsheets are utilized as a visual reminder to track and monitor due dates. 90 days prior to the due date the box will turn yellow. 60 days prior to the due date the box will turn red. CEO was re-trained on this policy and procedure and initialed the training to indicate understanding the responsibility. 09/06/2019 Implemented
6400.110(h)The agency's inoperable fire alarm policy does not include a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperable. There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative.Inoperable Fire Alarm Policy Fire Safety Monitoring System: If a smoke detector is found to be inoperable: Staff should notify a supervisor/PS immediately via phone. The supervisor/PS has 48 hours to correct any malfunctions. During the maintenance time period, staff should visually check the area of the house that has the malfunctioning alarm every 45 minutes. Once repairs are made, staff do not need to check the area every 45 minutes. During the time of in operation staff are required to physically walk to the area that has the inoperable alarm and will scan the area for fire. The PS will check each fire alarm monthly and will document the fire alarm maintenance check on the form that is provided. PS and DSW were all trained upon hire and then again trained annually. PS is responsible for ensuring that all fire alarms are working correctly. If an alarm is inoperable then the PS will contact the CEO for directives on replacement. The PS is to remove the inoperable alarm, replace the alarm with a working alarm, and check for corrections when the new alarm is installed. 08/30/2019 Implemented
6400.112(e)Fire drills were held during sleeping hours on 10/29/18 and then again on 8/13/19.A fire drill shall be held during sleeping hours at least every 6 months. Fire Drill During Sleeping Hours Fire drills are a mandatory requirement and all staff (CEO, PS, and DSW) are trained upon hire and then annually thereafter. CEO updated the Dire Drill Documentation to include a column for staff to circle ¿sleeping¿ or ¿awake¿. All staff were retrained on the fire safety policy that includes conducting the fire drill at least every 6 months during individual 1 sleep hours. PS is responsible for reviewing the fire drill form at least monthly to ensure that the fire drill was conducted and to track what date and time the sleeping drill was completed. To further ensure that this requirement is being met the sleep overnight fire drill date was added to out internal spreadsheet so that the office manager, CEO, and PS all are aware of the frequency of overnight sleeping fire drills. When a sleeping fire drill is completed then staff are to circle ¿sleep¿ on the form to indicate that the individual was in fact asleep before the drill occurred. All staff were trained on the new form. 08/30/2019 Implemented
6400.151(a)Direct Service Worker #1, date of hire 7/1/15, had a letter from the physician, dated 9/7/18, stating that Direct Service Worker #1 has been under his/her care and most recent physical examination was on 12/5/17. The documentation did not include a general physical examination and did not address communicable disease. 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. Triad will provide each staff with at least 30 days¿ notice when a compliance measure is needed. Dates are tracked on our internal spreadsheet which is reviewed by the PS, CEO, and Office Manager at least weekly to ensure compliance. The employee will have 30 days to complete the needed item. If the employee does not follow-thru with needed/requested items then the employee will be placed on un-paid leave. Once the items are completely corrected then the employee will be eligible to return to work. If the violation is not completed within 3 days of unpaid leave then Triad reserves the right to utilize ¿at will¿ employment and the employee will be terminated. PS, CEO, and Office Manager are responsible for checking spreadsheets. . Internal spreadsheets are utilized as a visual reminder to track and monitor due dates. 60 days prior to the due date the box will turn yellow. 30 days prior to the due date the box will turn red. PS was re-trained on this policy and procedure and initialed the training to indicate understanding the responsibility. A policy was created that outlined the DSW responsibility and all DSW signed the policy in agreement in order to avoid this occurring again. DSW#1 had a current physical and TB test however the documentation was lacking in the employee binder. PS, CEO, and Office Manager are to review employee binder charts at least monthly to cross-check the spreadsheet with the physical documentation that was provided. 08/30/2019 Implemented
6400.46(d)Direct Service Worker #1 was not certified in first aid, Heimlich techniques, and cardio-pulmonary resuscitation from 2/1/17 to 10/2/18. Direct Service Worker #1 transported individuals in a vehicle alone during this time.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.Triad will provide each staff with at least 30 days¿ notice when a compliance measure is needed. Dates are tracked on our internal spreadsheet which is reviewed by the PS, CEO, and Office Manager at least weekly to ensure compliance. The employee will have 30 days to complete the needed item. If the employee does not follow-thru with needed/requested items then the employee will be placed on un-paid leave. Once the items are completely corrected then the employee will be eligible to return to work. If the violation is not completed within 3 days of unpaid leave then Triad reserves the right to utilize ¿at will¿ employment and the employee will be terminated. PS, CEO, and Office Manager are responsible for checking spreadsheets. . Internal spreadsheets are utilized as a visual reminder to track and monitor due dates. 60 days prior to the due date the box will turn yellow. 30 days prior to the due date the box will turn red. PS was re-trained on this policy and procedure and initialed the training to indicate understanding the responsibility. A policy was created that outlined the DSW responsibility and all DSW signed the policy in agreement in order to avoid this occurring again. 09/06/2019 Implemented
6400.166(b)Azelastine 0.15% nasal spray, use 2 sprays in each nostril at bedtime prescribed to Individual #1 was not initialed as administered on 8/22/19 at 8:00 PM. Benzoyl Peroxide 5% wash, use twice daily to face neck and scalp was not initialed as administered on 8/23/19 at 8:00 PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication Record Training Policy Policy and Procedure for Medication Documentation is as followed: Program Specialist and Medication Trainer are responsible for training, modeling, and tracking correct medication administration documentation. DSW are responsible for ensuring accurate medication administration on each shift that requires medication to be administered. All staff are trained on medication administration and documentation both initially upon hire as well as yearly practicum training. Individual 1 was administered the medications at all times as prescribed. DSW did not initial the box on the MARS. PS is responsible to make sure all medications are administered and the Ps should review the MARS at least weekly for accuracy. If a discrepancy is present then the PS will address the discrepancy with the DSW during their next shift. All staff were retrained on this policy. 08/30/2019 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, dated 3/5/19, to the individual's plan team members on 3/5/19 for the annual ISP meeting on 3/19/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Policy and Procedure for Individual Assessment is as followed: Program Specialist is responsible for maintaining and updating the Individual assessment for individual #1. PS should review and update as needed as individual changes occur. At least 30 days prior to the scheduled ISP meeting the PS will submit the Individual assessment to the ISP team for their review. PS will include the ISP date on our agency tracking spreadsheet so that the format will change colors as the date approaches. The PS will read the ISP and note the annual meeting date. The PS will then use that date as the target date minus 30 days. CEO meets with PS monthly and CEO will also review dates to ensure that all dates are within compliance. Internal spreadsheets are utilized as a visual reminder to track and monitor due dates. 60 days prior to the due date the box will turn yellow. 30 days prior to the due date the box will turn red. PS was re-trained on this policy and procedure and initialed the training to indicate understanding the responsibility. 08/30/2019 Implemented
SIN-00140811 Renewal 08/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The interior stairs between the first floor and second floor of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Per ODP regulations, all interior steps and outside steps shall have a nonskid surface. All interior steps will be covered with a nonskid surface. Currently, carpet material is installed and securely fastened to each step. Program Specialist has added the carpet material to ensure safety and will visually check the stairs weekly, or as needed, to ensure that the carpet material is secure and does not represent a hazard. direct Care staff should report any surface that appears to be unsafe directly to the Program Specialist. The Program Specialist is responsible for ensuring household safety. [Immediately and upon hire, the CEO or designee shall educate all staff persons that interior stairs and outside steps shall have a nonskid surface and to report any disrepair or need for nonskid surface to the CEO or designee. At least monthly, the CEO or designee shall conduct a onsite walk through of the community home(s) to ensure the home(s) are do not have any physical site issues and there are not any hazards. Documentation of onsite checks shall be kept. (DPOC by AES, HSLS on 9/14/18)] 09/06/2018 Implemented
6400.151(c)(2)The physical examination, completed 12-5-17 for Program Specialist #1 did not include a Tuberculin skin test. 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. CEO will be responsible for ongoing staff records. CEO will monitor dates of physical and TB tests for all staff. Staff will be unable to work until the Tuberculin skin test has been administered and negative results have been documented. The TB test will be completed every two years. Program Specialist 1 had the Tuberculin skin test administered on 9/4/18 and read on 9/6/18. All staff will be trained on physical and TB test requirements. [Immediately and upon competition, the CEO shall audit all staff persons' current physical examination to ensure all required information as per 6400.151(c)(1)-(4) is included. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/14/18)] 09/06/2018 Implemented
6400.181(e)(14)Individual #1's assessment, completed 3-30-18 did not include assess the individual's knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The purpose of this policy is to provide staff with guidance on the measures required to ensure the safety of client 1 in the relation to water safety skills. CEO and Program Specialist will correct this by adding "Water Safety" to the annual assessment for ongoing usage. Immediately the Program Specialist will determine water safety by asking client 1 the questions below. Skill Area - Water Safey (pool, lake, ocean, river)- bodies of water Code Explanation/Comments Identifies appropriate swim wear Identifies water temperature enters water by walking in Enters by ladder or assistive device Identifies/recognizes depth of water Identifies/recognizes walk/don¿t run signs Understands meaning of walk/don¿t run signs Identifies men/women restrooms/dressing room Understands basic water safety skills Stand in water Underwater exploration Submerging mouth, nose, and eyes Identifies lifeguards Tread water Swim using arm strokes Swim using legs strokes Identifies the need for a life jacket Stable on uneven surface (sand, rocks, etc) How to call for help Use of diving board Exit pool by ladder When/If the situation arises, the Program Specialist can evaluate client 1 in the environment where the water is located. Client 1 has not shown any interest in water related activities. Direct Care Staff, CEO, and Program Specialist will review water safety protocols prior to any direct water related activities. Program Specialist will immediately verbally assess client 1 by asking the above stated assessment questions. Client 1 assessment is conducted yearly and will be reassessed yearly using the same rating scale. [Immediately, the Program specialist updated Individual #1's assessment to include Individual #1 ability to swim as "NO" and knowledge of water safety on 9/20/18. Immediately, the CEO shall educate the program specialist of the requirements of individual assessments as per 181(c)(1)-(14). Documentation of the training shall be kept. Upon completion of the training and at least annually, the Program specialist and CEO shall audit individual's current assessment to ensure all required information is included and accurate. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/14/18)] 09/06/2018 Implemented
SIN-00121067 Initial review 09/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The ceiling light in the laundry room was not operable. There was no other source of light in that area. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb in the laundry room had blown out and needed to be replaced. Triad replaced the light bulb today. In the future, if a light bulb needs to be replaced then the residential program director will replace the bulb immediately.[Immediately, the CEO shall develop and implement policies and procedures to ensure rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents to include staff duties, monitoring, reporting, replacing and repairing. Immediately and upon hire the CEO shall educate all staff person on the aforementioned policies and procedures. (AS 9/20/17)] 09/15/2017 Implemented
6400.67(a)The light switches on the walls in the bathroom on the first floor and in Bedroom #1 were exposed. Floors, walls, ceilings and other surfaces shall be in good repair. All outlets will have a light switch cover at all times. Residential Program Director shall monitor the outlets and should a light switch cover need a replacement, then the residential program director will purchase a replacement. During the time that a replacement is needed, the light switch will be covered with tape so that we can ensure safety at all times. [Immediately, the CEO shall develop and implement policies and procedures to floors, walls, ceilings and other surfaces shall be in good repair to include monitoring, reporting, replacing and repairing. Immediately and upon hire the CEO shall educate all staff persons on the aforementioned policies and procedures. Documentation of trainings shall be kept. (AS 9/20/17)] 09/15/2017 Implemented
6400.70The home did not have an operable telephone with an outside line. A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The phone and the phone line will be installed prior to an individual living in a home. The home land line will be noncoin-operated and available for use. the residential program director will be responsible for making sure that the phone line is in working order and should any repairs be needed, the residential program director will report the issue to the CEO and the CEO will contact the phone company immediately to report an issue. If the phone is out of order for more than a reasonable amount of time, then CEO will purchase a tracfone so that the individual is not without access to a phone. [Immediately, the CEO shall identify and contact a telephone provider to ensure an operable telephone will be installed prior to individuals' moving in to the home. Immediately and upon hire, the CEO will educate all staff persons on the location and use of the telephone to include the need and usage of required posted telephone numbers. Documentation of trainings shall be kept. (AS 9/20/17)] 09/15/2017 Implemented
6400.80(a)A four feet by two feet cement slab nearest the porch of the walkway in front of the home was uneven and pitched forward when stepped on, posing a tripping hazard. In addition, there were two cement blocks along the side of the walkway which were loose, posing a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. Triad has removed the cement slab that was identified as being a tripping hazard. Triad removed the two identified blocks that were loose. In the future, Triad will walk the perimeter of the property to ensure that the walkway is safe and that unsteady surfaces are removed, replaced, or repaired. The residential program director will be the person identified who will walk the perimeter of the monthly weekly and then report any issues directly to the CEO. The CEO will be responsible for making sure the correction is made in a 24 hour time period. During the 24 hour time period, Triad will ensure safety by roping off the area that is unsafe so that the space can be avoided until it is safe.[Immediately, the CEO shall develop and implement policies and procedures to ensure outside walkways are free from ice, snow, obstructions and other hazards to include staff duties, monitoring, reporting, replacing and repairing. Immediately and upon hire the CEO shall educate all staff person on the aforementioned policies and procedures. Documentation of trainings shall be kept.(AS 9/20/17)] 09/15/2017 Implemented