| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | No ODP self-assessment completed. | 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.
| Settime Inc will complete a self-assessment of each home it operates and individuals ID, within 3 to 6 months prior to the expiration date of its certificate of compliance. |
04/07/2022
| Implemented |
| 6400.43(b)(1) | The agency's COVID policy required both staff and individuals to always wear masks when inside the individual's residence, rather than just the staff providing service. During the inspection, the agency submitted a revised policy that still included the masking requirement for staff, but no longer required an individual to always wear a mask in their home. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The CEO will be responsible for the administration and general management of the home, including the following: the Implementation of Policies and Procedures. The CEO will modify the COVID Policy to state that staff will wear mask when inside the individual's residence and not the individual. |
04/07/2022
| Implemented |
| 6400.62(c) | A decorative hand-soap dispenser was observed in the bathroom, containing a viscous material consistent with hand-soap. Poisons must be kept in their original labeled packaging. | Poisonous materials shall be stored in their original, labeled containers. | Agency Management and Staff will ensure that hand-soap dispenser and other Poisonous materials are stored in their original, labeled containers. |
04/07/2022
| Implemented |
| 6400.64(a) | A dark grey material consistent with dust or grime was observed caked into the openings of the vent in the bathroom. A dark material consistent with dust was also observed clumped up in the center of the interior of the ceiling light plastic cover in the kitchen. | Clean and sanitary conditions shall be maintained in the home. | Agency Management and Staff will ensure that the vent in the bathroom, the ceiling light plastic cover in the kitchen will be cleaned regularly by Staff. |
03/24/2022
| Implemented |
| 6400.64(b) | Pest traps were observed beneath the cabinets on either side of the kitchen stove. During the inspection, staff indicated the property has occasional pest issues that arise from the apartment complex's inadequate trash disposal, that the complex's bins are often overstuffed and that this attracts vermin that sometimes get into the apartment. The agency later submitted documentation showing they had scheduled pest control services with the property management for 3/2/22. | There may not be evidence of infestation of insects or rodents in the home. | Agency Management will ensure that the Rental Office will complete pest control services in the Home as scheduled by their Office and upon our request. Pest Control services was completed in the Home on 3/2/22. |
03/31/2022
| Implemented |
| 6400.67(a) | The plastic surface on the lower right corner of the microwave door is cracked. The lower left corner of the medicine cabinet door in the bathroom is damaged, a chunk of paint and wood chipped off, making a small, shallow divot in the surface of the cabinet. | Floors, walls, ceilings and other surfaces shall be in good repair. | Agency will follow State Regulation by carrying on repair of floors, walls, ceilings and other surfaces shall be in good repair. Agency will be repair Microwave, medicine cabinet in bathroom door will be repair or replace. |
03/24/2022
| Implemented |
| 6400.141(c)(3) | Immunizations not found on Individual 1's physical exam dated 4/29/21 - left blank. | 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. | The Agency Management will ensure that before individuals are admitted into the 6400 programs, have a complete physical completed. Agency will have all individuals annually physical done with all Immunizations completed in accordingly with CDC Regulations. |
04/07/2022
| Implemented |
| 6400.141(c)(10) | Physical exam Communicable disease portion lists Individual 1 as "no"-not being free of communicable disease-no follow up provided | 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. | Agency will ensure that Annual Physical Exam is completed for each individual and specific precautions that must be taken, if the individual has a communicable disease, in order to prevent spread of the disease to other individuals. If the Individual does not have a communicable disease, it must be noted on the Physical Report by the PCP. |
03/31/2022
| Implemented |
| 6400.141(c)(14) | Physical exam section regarding information pertinent to diagnosis in case of an emergency was listed as n/a. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Agency management will ensure that all individuals Annual Physical Exam Form are completed and well documented by the individual's PCP, with information pertinent to diagnosis and treatment, in case of an emergency. An Annual Physical has been scheduled for 3/25/2022. |
04/07/2022
| Implemented |
| 6400.142(a) | No dental exam found in Individual 1's record. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Agency will ensure that all individuals 18 years of age or older shall have a dental examination performed by a licensed dentist annually. A Dental Appointment has been scheduled for 4/7/2022 |
03/31/2022
| Implemented |
| 6400.144 | It cannot be determined that pharmaceutical services are being rendered for Individual 1. Their medication kit contained a blister pack that held a week's worth of two different medications: Jardiance and Gabapentin. The Jardiance is to be taken once daily, with one pill administered in the morning; the Gabapentin is taken three times daily, with two pills taken twice a day, and then three pills taken daily at bedtime. Several days' pills had been removed, partially replaced, and taped over: 2/21/22, 2/25/22, and 2/26/22's. For all three of these days, only the Gabapentin had been replaced, not the Jardiance. Staff initialed the MAR for the individual's Gabapentin on 2/21/22, but the pills were replaced in the blister pack, so it cannot be determined that they were administered. Also, the missing Jardiance pills were not in the medicine kit, and the house did not have replacements/a refill on-site. Further, several packs of extra-strength Tylenol were found in the first aid kit in an unlocked hallway closet. The medication is not reflected on the individual's MAR. Individual 1's follow up vision appt for 12/17/21 not scheduled or found in record, and follow up hearing appt for 12/20/21 not scheduled or found in record. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Agency will ensure that all individuals receiving services from SETTIME INC received all Health Services. Agency has requested the Pharmacy (Ganse) have each Medication placed in Individual Blister packs. Agency has requested the pharmacy not to put medication together in one blister pack. Agency has requested the pharmacy to deliver all Individual's medication one-week prior to the end of the month.
The first aid kit with several packs of Tylenol has been placed in the lock Medication cabinet. |
03/24/2022
| Implemented |
| 6400.151(a) | For Staff Member 2, no physical exam found in record, requested but not provided. | 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. | Agency will ensure that all staff who come 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. |
04/07/2022
| Implemented |
| 6400.168(d) | For Staff Member 1, no annual med training practicum found in record; last med admin training conducted 9/23/20. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Agency Management will ensure that all Staff who administer prescription medications to an Individual shall complete and pass the Medications Administration Course Practicum annually. |
04/07/2022
| Implemented |
| 6400.217 | Consent for release of information including being photographed was not included in Individual 1's record. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The Agency will include in its Intake Package, a Written Consent for release of information, including photographs, to persons not otherwise authorized to receive it. |
04/07/2022
| Implemented |
| 6400.15(b) | Facility Inspection checklist provided in lieu of the self-assessment. Agency shall use ODP's licensing inspection instrument to measure and record compliance for community homes for individuals with id. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The Agency will on a weekly basic conduct a facility inspection of community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. |
04/07/2022
| Implemented |
| 6400.31(b) | List of rights for Individual 1 found in the record is incomplete. Re-requested but not provided. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | The Agency will provide to each individual list of their rights during intake procedure. The Agency will include the right of the individual to education, assist and provide the accommodation necessary for the individual to make choices and understand the individual¿s rights. |
04/07/2022
| Implemented |
| 6400.46(b) | For Staff Member 1, fire safety training completed 9/25/2019-9/18/2021-not within the annual timeframe. For Staff Member 2, annual fire safety training requested, but not provided; annual fire safety training not provided by fire safety expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Agency will ensure that the Program Specialist and Direct Care Workers are trained annually by a Fire Safety Expert in the training areas specified in subsection (a). Training records will be kept in the Staff Training File. |
04/07/2022
| Implemented |
| 6400.46(d) | For Staff Member 1, first aid training last completed 6/18/19- not completed within the annual or 2-year timeframe. For Staff Member 2, first aid training requested, but not provided. | 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. | Agency will ensure that the Program Specialist, Direct Service Workers (drivers) shall be trained within 6 months after the day of initial employment and annually thereafter, by an Individual Certified as a by Hospital or other recognized health care organization, in First Aid, Heimlich techniques and Cadio Pulmonary Resuscitation (CPR). |
04/15/2022
| Implemented |
| 6400.50(b) | For Staff Member 2, the training record for the calendar year ending 2021 was requested, but not provided. Only training records for 2020/2022 were provided. | The home shall keep a training record for each person trained. | Agency will train all Staff annually. Training Records for each Staff will be kept in the Home. |
04/15/2022
| Implemented |
| 6400.52(a)(1) | For Staff Members 1 and 2, 24 hours of training not provided for training year Jan 1- Dec 31, 2021. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Administrator will ensure that Program Specialist and Direct Service Workers will complete 24 hours of Training, related to their job skills and knowledge, each year. |
04/15/2022
| Implemented |
| 6400.52(b)(1) | It cannot be determined that the CEO completed 12 hours of annual training in 2021. Documentation submitted only accounted for 5 hours in 2021, and the training submitted did not address the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, individual rights, or recognizing and reporting incidents. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | The CEO, Management, Program, Administrative and Fiscal Staff persons will complete 12 hours of Training each year. |
04/15/2022
| Implemented |
| 6400.163(a) | Two loose yellow pill capsules with SG-180 printed on them, consistent with the individual's Gabapentin medication, were observed in the bottom of Individual 1's medication kit. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Agency management will ensure that all individuals medications are kept in the correct and original labeled container. |
04/15/2022
| Implemented |
| 6400.166(a)(11) | Individual 1's MAR does not contain a record of the diagnoses or purposes for the medications listed on it. | 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. | Agency will ensure that all individuals Medication Record shall be kept, including the following: Diagnosis or purpose for the medication, including pro re nata. |
04/15/2022
| Implemented |
| 6400.182(c) | No ISP found in Individual 1's record. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Agency will ensure that the Individual's ISP is revised annually, printed and placed in the Individual's Program Book.
Individual's revised ISP was re-sent on 2/25/2022. |
04/15/2022
| Implemented |
| 6400.213(1)(i) | Demographics not provided for Individual 1 - hair color, eye color. Identifying marks - requested, not provided. Primary language, communication, religious affiliation not found in record - requested but not provided. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Agency will during the intake process have a face sheet which include individual name, sex, admission date, birthdate and Social Security number and placed in the individual's book. |
04/15/2022
| Implemented |