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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(13) | Individual #1's physical examination, dated 8/9/2022, did not address Allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | 6400.141(c)(13)- (c) The physical examination shall include: (13) Allergies or contraindicated medications. 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 8/9/22 did not address allergies or contradicted medications (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 8/9/22, was returned to the medical provider for completion of the individual's allergies and contraindicated medications on 12/1/22 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 |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | During the 12/01/21 there was a 1A rated fire extinguisher located in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen.
The kitchen extinguisher meets the requirements for one floor as required in subsection (a)
6400.111(c) 12/1/2021 (date of inspection) the kitchen had two fire extinguishers. The fire extinguisher hanging on the wall was reportedly a 1A. There is a second extinguisher that meets the 2a-10bc regulation. This was an oversight of having a 1A hanging on the wall. The 2A-10BC should have the primary area on the wall space. This violation was due to an oversight of not clearly marking the primary extinguisher for kitchen usage.
Program Specialist immediately on 12/1/2021 notified CEO of the excess fire extinguishers. Program Specialist immediately moved the larger extinguisher to the countertop and moved the 1A to the floor. 12/1/2021 this violation was corrected by moving the 1A off the wall and onto the floor and moving the 2a10-bc to the countertop.
Per technical assistance, Program Specialist collected excess 1A fire extinguishers and removed from premises so that there is not confusion on which fire extinguisher to use in case of emergency.
12/1/2021 compliance with 6400.111c was updated. |
12/04/2021
| Implemented |
| 6400.163(d) | During the 12/01/2021 inspection over-the-counter Diphenhydramamine HCL 25mg caplets, with instructions to take 1 to 2 caplets every 4 to 6 hours as needed and Acetaminophen 325mg tablets, with instructions to take 2 tablets every 4 to 6 hours as needed, were identified unlocked in the first aid kit. Individual #1's most recent assessment completed 12/15/2020 documents the individual is unable to self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 6400.163(d) ¿ Prescription medication and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.
12/1/2021 (date of inspection) the first aid kit contained a packet of Benadryl and a packet of Tylenol. This was a violation as all prescription medications need to be in medication lock box. The first aid kit is a standard kit and it was an oversight to not investigate the contents of the first aid kit.
Program Specialist immediately on 12/1/2021 notified CEO and Medication Admin Trainer of the medication packets and Direct Care staff immediately flushed packets of Tylenol and Benadryl. Program Specialist immediately removed all medication packets from the first aid kit and rechecked the contents to ensure that all necessary supplies are in the first aid kit and removed all items that are not on the required list.
Per technical assistance, Program Specialist and Direct Care staff removed medication packets immediately upon being informed so that there is not an opportunity to accidentally ingest medication packets.
12/1/2021 compliance with 6400.163d was updated.
The steps Program Specialist took was on 12/1/2021 notify the CEO and Medication Admin that this home had a packet of Tylenol and a packet of Benadryl located in the first aid kit. Program Specialist immediately removed packets and the packets were disposed of on 12/1/2021. |
12/04/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's December 2021 medication administration record did not include the diagnosis or purpose for the following medications: Lamotrigine 150mg tablet, Loratadine 10mg tablet, Lorazepam 0.5mg tablet, Melatonin Tr 10mg tablet, Senexon-S 50-8.6mg , Topiramate 100mg tablet, Topiramate 50mg , Ziprasidone Hcl 20mg Cap, Deep Sea 0.65% nose spray, Gnp Saline Nasal Spray 44ml, and Mapap X-Str Tab 500mg. | 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.
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12/20/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit did not contain tweezers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | In an effort to maintain "everyday lives", the individual prefers to keep tweezers with him and have immediate access to tweezers. As a result, the tweezers from the first aid kit were not present (in the first aid kit) during inspection. Program Specialist immediately purchased and placed a 2nd pair of tweezers in the first aid kit. A picture of the item was sent to inspector the same day as inspection. Program Specialist and direct care staff were retrained on first aid safety and what is needed in order to have a complete first aid kit. Program Specialist and direct care will monitor items in the first aid kit at least monthly to ensure that all contents are accounted for. If needed, additional items will be purchased within 24 hours of violation. |
12/15/2020
| Implemented |
| 6400.111(a) | There was not a fire extinguisher in the basement of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Triad will maintain compliance standards by following 6400.111(a). At this location two fire extinguishers were present. During inspection, one fire extinguisher was moved immediately to the unfinished basement. Thus, one fire extinguisher is located in the kitchen and the other is located in unfinished basement. Moving forward, Program Specialist and direct care staff will obtain visual location of each fire extinguisher on a daily basis. Staff will visually identify the fire extinguisher at each location (kitchen and unfinished basement) on a daily basis by intentionally looking for both extinguishers. All staff were re-trained on fire safety and the need to have the fire extinguishers at certain and specific locations. [Immediately, the CEO shall audit the fire safety training syllabus to ensure all staff are educated upon hire and at least annually on the requirements of fire extinguishers as per 6400.111a-111f. Immediately, the CEO or Designee shall reeducate all staff persons on the requirements as needed to ensure the safety of all individuals in the event of a fire. Documentation of all trainings shall be kept. (DPOC by AES,HSLS on 12/29/20)] |
12/15/2020
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination, completed 9/10/2020 does not address 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 on 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)(14) | Individual #1's physical examination, completed 9/10/2020 does not include 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. | 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 on 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(a) | Direct Service Worker #1, date of hire 4/5/20 had an initial physical examination completed 7/5/20. [Repeat Violation - 8/26/19] | 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 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 (a) (b) (c) and 6400.152 (a) (b) (c) Due to COVID and the age of the DSW#1 we felt that as an agency we cannot force an employee to visit an urgent care center during a global pandemic. DSW#1 was hired in the beginning of the pandemic and then felt safe to complete the exam in July 2020 once the COVID numbers decreased. Moving forward we will not hire an employee during a pandemic as we would be unable to ensure an initial physical examination would be completed in a timely manner. [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 to ensure the health and safety of the individual 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 |
| 6400.151(c)(2) | Direct Service Worker #1, date of hire 4/5/20 had an initial Tuberculin test completed 6/28/20. | 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. | 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 (a) (b) (c) and 6400.152 (a) (b) (c) Due to COVID and the age of the DSW#1 we felt that as an agency we cannot force an employee to visit an urgent care center during a global pandemic. DSW#1 was hired in the beginning of the pandemic and then felt safe to complete the TB test in June 2020 once the COVID numbers decreased. Moving forward we will not hire an employee during a pandemic as we would be unable to ensure a TB test and read would be completed in a timely manner. [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 |
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