| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(h) | 7/7/2017 fire drill did not indicate if individuals met at the designated meeting place. Unable to determine who chairperson is. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | It is important that all fire safety procedures are implemented and documented properly to assure the home/individuals are safe. The violation occurred because the staff did not circle yes that everyone met at the meeting place. To prevent future occurrence, the staff are responsible to document if all residents and staff evacuate to the designated meeting place. (Attachment #1) The Team lead will review the Community Homes Monthly Fire Drill Report monthly to assure compliance with this regulation for all homes. Team Leaders were trained on this regulation and their responsibility in meeting the regulation. (Attachment #8) The vice president will train the Team Leads and all staff on this regulation 6400.112(h) and will ensure that the entire agency has reviewed this regulation and will be completed by 8/31/17 |
08/31/2017
| Implemented |
| 6400.144 | Individual #1 is prescribed an epi-pen due to peanut allergy. Medication is not taken with him during community outings or any other time he leaves his residence. | 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.
| The medical coordinator will review each individuals medical record and train all staff on the individuals allergies and in regulation §6400.144. The training will ensure that for each individual who has allergies, staff will be properly equipped with an epi-pen to treat an allergic reaction on outings if such of an event should occur. Proper training in this regulation and allergies to each individual will ensure staff can respond to an allergic reaction. A locked box will be placed in each individuals home or vehicle to ensure that an epi-pen will be provided during an outing. The medical coordinator will ensure that the staff for each individual will be trained on that specific individuals allergies and trained on how to use an epi-pen. The vice president will train the Medical Coordinator and all staff on this regulation 6400.144 and will ensure that the entire agency has reviewed this regulation and will be completed by 9/30/17 |
09/30/2017
| Implemented |
| 6400.163(c) | Individual #1's 7/10/17 and 10/4/16 psychiatric medication reviews did not include medications or dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | It is important that the psychiatric doctor reviews all psychiatric medications. This violation occurred because the Team Lead did not attach the physicians orders to the psychiatric appointment summary. All Team leads who directly support the individuals were trained on regulation 6400.163(c) and responsibility on this regulation on 7/26/2017. They will ensure that the copy of the physicians orders which list all medication will be attached to the appointment summary prior to an appointment so the psychiatric doctor can review all medications. The medical coordinator will ensure that each individuals medical record will include the medications and dosage is listed on the physicians orders that is attached to the appointment summary. Please see attachment number 8. The vice president will train the Medical Coordinator and all staff on this regulation 6400.163(c) and will ensure that the entire agency has reviewed this regulation and will be completed by 9/30/17 |
09/30/2017
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment dated 5/23/2017 did not include current level of performance and progress in the area of personal adjustment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | The Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181 This will also ensure that there was progress or performance in the area of personal adjustment § 6400.181(e)(3)(iii) and all areas of the assessment. The vice president will train the Program Specialist on this regulation 6400.181(e)(3)(iii) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment dated 5/23/2017 did not include need for supervision. Individual #1 receives 3:1 staffing. | The assessment must include the following information: The individual's need for supervision.
| The Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181(e)(4) This will also ensure that there was proper documentation for all individuals staffing ratios for the individuals need for supervision and all areas of the assessment.The vice president will train the Program Specialist on this regulation 6400.181(e)(4) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment dated 5/23/2017 did not include progress over the past year in the area of communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181(13)(ii) This will also ensure that the Program Specialist will update each individuals record to include progress over the last 365 days in the area of communication skills. and all areas of the assessment. The vice president will train the Program Specialist on this regulation 6400.181(13)(ii) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's assessment dated 5/23/2017 did not include progress over the past year in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181(13)(v) This will also ensure that the Program Specialist will update each individuals record to include progress over the last 365 days in the area of socialization and all areas of the assessment. The vice president will train the Program Specialist on this regulation 6400.181(13)(v) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment dated 5/23/2017 did not include progress over the past year in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181(13)(vi) This will also ensure that the Program Specialist will update each individuals record to include progress over the last 365 days in the area of recreation and all areas of the assessment. The vice president will train the Program Specialist on this regulation 6400.181(13)(vi) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment dated 5/23/2017 did not include information regarding 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 Program Specialist created a new assessment outline / form taken directly from § 6400.181. All items from the regulation § 6400.181 was added to the new assessment. The program specialist will review each individuals record and make the necessary updates to all assessments to include the new outline / form and notify each supports coordinator as to any said updates so an appropriate update can be made to the individuals ISP. The new assessment will ensure that each individuals record will be updated and what each individuals ability is in all specified areas on regulation § 6400.181(14) This will also ensure that the Program Specialist will update each individuals record to include progress over the last 365 days in individuals level of knowledge of water safety and their ability to swim and all areas of the assessment. The vice president will train the Program Specialist on this regulation 6400.181(14) and will ensure that the entire agency has reviewed this regulation and will be completed by 12/31/17 |
12/31/2017
| Implemented |
| 6400.186(c)(2) | Individual #1's ISP reviews did not include information and/or updates regarding his behavior support plan, SEEN, and dental plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The Program Specialist will review each individuals ISP review / Quarterly review has a section addressing a behavior support plan, seen plan and a dental plan. The Program Specialist will also ensure that for each individual on a behavior support plan that there are updates for the review period to include the amount of physical interventions used or properly document no physical interventions used during this reporting period. The Program Specialist will also review all individual records to update the ISP review / Quarterly review for a dental plan & SEEN plan and will be updated accordingly to each reporting period in accordance with § 6400.186(c)(2). Proper ISP reviews will ensure each item is documented properly and for future reporting periods for each individual.The vice president will train the Program Specialist on this regulation 6400.186(c)(2) and will ensure that the entire agency has reviewed this regulation and will be completed by 9/15/17 |
09/15/2017
| Implemented |
| 6400.186(e) | All team members were not notified of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The declination sheet has been distributed to all team members that provide services to the individual. When a new team member is presented, a declination sheet will be provided to that person, so that they will have the opportunity to accept or decline ISP review documentation. The Vice President has trained the Program Specialist on training verification form. The Program Specialist will also review each individuals record for ISP quarterly reviews and add a declination signature page for all team member to either accept or deny any quarterly ISP review that has information contained from the ISP, Progress notes, observations etc. The proper documentation will ensure that each team member will have the chance to review or deny any information contained from the ISP for each individual in accordance with § 6400.186(e). The vice president will train the Program Specialist on this regulation 6400.186(e) and will ensure that the entire agency has reviewed this regulation and will be completed by 9/15/17 |
09/15/2017
| Implemented |
| 6400.195(d) | Chairperson did not sign and date Individual #1's restrictive procedure plan. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| A new Human Rights Committee form will be created to ensure that each person on the Human Rights Committee is identified on a signature sheet and the majority of persons on the committee do not directly work with the individual. The signature sheet will also ensure that the chair person will be identified and will be taken to each review. Also the new form will ensure that proper documentation will be kept for all individuals who are on a restrictive procedure plan in accordance with § 6400.195.(d) The Program Specialist will ensure that the new Human Rights Committee sheet is created and will ensure that it is taken to each individuals review. The vice president will train the Program Specialist on this regulation 6400.195(d) and will ensure that the entire agency has reviewed this regulation and will be completed by 9/30/17 |
09/30/2017
| Implemented |
| 6400.195(e)(5) | Individual #1's restrictive procedure plan did not include a target date for achieving the outcome. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| A new Restrictive Procedure Plan was created by the Program Specialist to ensure that each item from regulation § 6400.195 (e)(5) is included in each individuals restrictive procedure plan. The Program Specialist will review each individuals restrictive procedure plan to ensure that there is a target date specified. The program specialist will also send each individuals restrictive procedure plan to the committee prior to each individuals meeting date to ensure a proper review of each restrictive plan is in accordance with regulation § 6400.195(e)(5) The vice president will train the Program Specialist on this regulation 6400.195(e)(5) and will ensure that the entire agency has reviewed this regulation and will be completed by 11/16/17 |
11/16/2017
| Implemented |