| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no indication that a self-assessment was completed for 881 2nd St. The self-assessment forms did not include the address information for which residential home the self-assessment was completed for. The legal entity address, which differs from each home address location, was recorded on all self-assessment forms | 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.
| 1. The CEO trained Vice President on regulation 6400.15A on 09/04/2018 to have addresses properly identified on the self-assessment.
2. All other locations were not in compliance with this regulation. This violation was addressed by the licensor on 08/29/2018 during on-site inspection.
3. The President and Vice President and house team leads were trained on regulation 6400.15A by the CEO to ensure that all self-assessments will have the proper addresses listed with reference to Regulation 6400.15A. The President, Vice-President and House Team Leads will sign off on signature paper by 12/31/2018.
4. The CEO will review with the Vice President the self- assessments on a yearly basis to ensure compliance. |
10/12/2018
| Implemented |
| 6400.67(a) | Individual #1's tall dresser across from the bottom of their bed is missing the knob on the bottom drawer on the right side. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. A maintenance request from was sent on 08/30/2018 to have knobs installed on the dresser.
2. On 09/04/2018 the quality compliance manager checked all other homes. All other homes were in compliance with this regulation.
3. All staff will be trained on regulation 6400.67a by the quality compliance manager to ensure that all knobs are on dressers. Staff will sign off on a training signature paper by 12/31/2018.
4. On a weekly basis, the quality compliance manager will make sure that all dressers have knobs starting on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.74 | The basement steps were not equipped with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| 1. It is important to have non-skid surfaces on interior and exterior steps to help assure the safety of
individuals. On 9/08/2018, non-skid strips were added basement steps.
2. On 09/04/2018 the quality compliance manager reviewed all other house locations to make sure
that all interior and exterior steps have non-skid surfaces. All other locations were in compliance
with this regulation.
3. All staff will be trained by the licensed compliance manager on regulation 6400.74 to ensure that
all interior and exterior steps have non-skid surface. Staff will sign off on training signature paper
by 12/31/2018.
4. On 11/01/2018, quality compliance manager will check on a weekly basis that all interior and
exterior steps to have non-skid strips for all houses. |
10/12/2018
| Implemented |
| 6400.142(f) | Individual #1, who has not reached dental hygiene independence, does not have a written plan for dental hygiene independence. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | 1. On 8/30/2018 the Program Specialist immediately updated revised assessment to include Dental Plan of Care.
2. On 09/04/2018- 09/06/2018 the Program Specialist reviewed all individual assessments and made sure all dental plan of cares will outline the level of supervision required, what level of verbal prompting, gestural prompting and physical prompting that each individual requires, with brushing, flossing and rinsing. If an individual has achieved dental hygiene independence that also would be reflected in their ISP and assessment.
3. All staff including Program Specialist will be trained on regulation 6400.142f Implementing Dental Plan of Care in Assessment by Vice President and sign off on training signature paper by 12/31/2018.
4. The Program Specialist will review all assessments on a quarterly basis to ensure that Dental Care of Plan is included and revised as deemed necessary starting 01/2019. |
10/05/2018
| Implemented |
| 6400.181(e)(1) | Individual #1's 12/30/17 assessment did not include preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 1. On 08/30/2018 the Program Specialist added into the assessment the functional strengths, needs and preferences.
2. On 09/04/2018- 09/08/2018 the Program Specialist reviewed all other individual¿s files to ensure that the functional strengths, needs and preferences were addressed in the assessment. All other individual¿s files included functional strength, needs and preferences within the assessment.
3. All staff including the Program Specialist will be trained by Vice President on Regulation 6400.181 e 1 to include that all assessments include the functional strengths, needs and preferences. All staff will sign off on training signature sheet by 12/31/2018.
4. The Program Specialist will review all individual¿s assessments on a quarterly basis to ensure that functional strengths, needs and preference are addressed in the assessment starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(7) | REPEAT from 7/12/17 annual inspection: Individual #1's 12/30/17 assessment did not include his/her ability to sense and move away quickly from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | 1. On 08/30/2018 the Program Specialist added into the assessment the individual¿s ability to sense and move away quickly from heat sources.
2. On 09/04/2018-09/08/2018 the Program Specialist reviewed all other individual¿s files to ensure that assessments included the individual¿s ability to sense and move away quickly from heat sources. All other individual¿s files included the individual¿s ability to sense and move away quickly from heat sources.
3. All staff including Program Specialist will be trained by Vice President on Regulation 6400.181 (7) to include that all assessments include the individual¿s ability to sense and move away quickly from heat sources. All staff will sign off on training signature sheet by 12/31/2018.
4. The Program Specialist will review all individual¿s assessments on a quarterly basis to ensure that the individual¿s ability to sense and move away quickly from heat sources are addressed in the assessment starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(12) | Individual #1's 12/30/17 assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. On 08/30/2018 the Program Specialist revised the assessment to put in the recommendations for specific areas of training, programming and services.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that recommendations for specific areas of training, programming and services are in the assessment. All other assessments were found to be in compliance with recommendations for specific areas of training, programming and services be included in the assessment.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(12) to include that all assessments include the recommendation for specific areas of training, programming and services are in the assessment. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.186(d) | There was no documentation to indicate who Individual #1's 6/28/18, 3/31/18, 1/2/18 and 10/2/17 Individual Support Plan (ISP) reviews were sent to. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | 1. On 08/31/2018 the Program Specialist revised the ISP reviews to include the specific team members that received the ISP reviews.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual ISP reviews to ensure that the ISP reviews indicated the name of the specific team members that received the assessment. The Program Specialist made changes to all other ISP reviews to indicate the specific team members name that received the assessment.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.186(d) to include that the name of the specific team members that received the ISP reviews. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that ISP reviews are correct and up to date with specific team signatures starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.186(e) | REPEAT from 7/12/17 annual inspection: Individual #1's mother was not offered the option to decline Individual #1's Individual Support Plan (ISP) review information. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | 1. On 08/30/2018 the Program Specialist offered all team members the opportunity to review the ISP. The individual¿s mother is in jail and is not able to decline at this time.
2. On 09/04/2018 the Program Specialist reviewed all other individual¿s files to ensure that all team members were given the opportunity to review the ISP. All other individual¿s files were in compliance.
3. All staff including Program Specialist will be trained by Vice President on Regulation 6400.186 e to include that all team members are given the opportunity to review individual¿s ISP. All staff will sign off on training signature sheet by 12/31/2018.
4. The Program Specialist will review all individual¿s ISP on a quarterly basis to ensure that all team members will be given the opportunity to review the ISP starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(e)(1) | Individual #1's restrictive behavior plan does not include the behaviors to be address and the suspected antecedent or reason for the behavior regarding the home telephone, personal cell phone, iPod, and internet usage. | The restrictive procedure plan shall include: The specific behavior to be addressed and the suspected antecedent or reason for the behavior.
| 1. On 08/30/2018, the Behavioral Specialist Consultant developed in restrictive plan the suspected antecedent for behavior regarding home telephone, personal cell phone, I-Pod and internet usage.
2. On 09/04/2018-09/08/2018 the Behavioral Specialist went through all other individuals¿ restrictive plans to ensure that suspected antecedents for behavior were included in all restrictive plans. All other restrictive plans had antecedents for behaviors within the restrictive plan.
3. All staff including the Behavioral Specialist will be trained by 12/31/2018 by the CEO on regulation 6400.195 e1 to ensure that all suspected antecedents for behavior are included in all restrictive plans. All staff will sign off on training signature paper.
4. The Behavioral Specialist Consultant will review all individual¿s restrictive plans on a quarterly basis to ensure that suspected antecedents for behavior are included in all restrictive plans starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(e)(2) | Individual #1's restrictive behavior plan does not include the single behavioral outcome desired stated in measurable terms for the home telephone, personal cell phone, iPod, and internet usage. | The restrictive procedure plan shall include: The single behavioral outcome desired stated in measurable terms. | 1. On 08/30/2018, the Behavioral Specialist Consultant included single behavioral outcome stated in measurable terms for individual¿s home telephone, personal cell phone, I-Pod and internet usage.
2. On 09/04/2019-09/08/2018 the Behavioral Specialist Consultant went through all other individuals¿ restrictive plans to ensure that behavioral outcomes were stated in measurable terms. All other restrictive plans had behavioral outcomes that were stated in measurable terms.
3. All staff including the Behavioral Specialist will be trained by 12/31/2018 by the CEO on regulation 6400.195 e2 to ensure that all behavioral outcomes are stated in measurable terms in restrictive plans. All staff will sign off on training signature paper.
4. The Behavioral Specialist Consultant will review all individual¿s restrictive plans on a quarterly basis to ensure that all behavioral outcomes are stated in measurable terms in restrictive plans starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(e)(3) | Individual #1's restrictive behavioral plan does not include the methods for modifying or eliminating the behavior for the restrictions around the home telephone, personal cell phone, iPod, and internet usage. | The restrictive procedure plan shall include: Methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior.
| 1. On 08/30/2018 the Behavioral Specialist Consultant made modifications in restrictive plan involving individual¿s home telephone, personal cell phone, I-Pod and internet usage to include methods for modifying or eliminating behavior including changes in the individual¿s physical and social environment.
2. On 09/04/2018- 09/08/2018 the Behavioral Specialist Consultant went through all other individuals¿ restrictive plans to ensure that modifications were made within interventions to methods for modifying or eliminating behaviors. All other restrictive plan included methods for modifying or eliminating behaviors.
3. All staff including the Behavioral Specialist will be trained by the CEO by 12/31/2018 on regulation 6400.195 e3 to ensure that all restrictive plans include methods for modifying or eliminating behaviors. All staff will sign off on training signature paper.
4. The Behavioral Specialist Consultant will review all restrictive plans to ensure that all restrictive plans include methods for modifying or eliminating behaviors starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(e)(4) | Individual #1's restrictive procedure plan does not include the home telephone, personal cell phone, iPod, and internet usage and the circumstances under which these restrictions may be used. | The restrictive procedure plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used.
| 1. On 08/30/2018, the Behavioral Specialist Consultant made modifications in restrictive plan to include the types of restrictive procedures that may be used and the circumstances in which electronics would be disabled from the individual.
2. On 09/04/2018- 09/08/2018 the Behavioral Specialist Consultant went through all other individuals¿ restrictive plans to ensure the circumstances of when restrictive procedures may be used. All other restrictive plans included the circumstances of when restrictive procedures may be used.
3. All staff including the Behavioral Specialist Consultant will be trained by the CEO by 12/31/2018 on regulation 6400.195 e 4 to ensure that all restrictive plans include circumstances when restrictive procedures may be used. All staff will sign off on training signature paper.
4. The Behavioral Specialist Consultant will review all restrictive plans to ensure that all restrictive plans include circumstances when restrictive procedures may be used starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.195(e)(5) | REPEAT from 7/12/17 annual inspection: Individual #1's restrictive procedure plan does not include a target date for his/her restrictions to the home telephone, personal cell phone, ipod, and internet usage. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| 1. On 08/30/2018, the Behavioral Specialist Consultant included in a target date for individual¿s restriction on home telephone, personal cell phone, I-Pod and internet usage.
2. On 09/04/2018- 09/08/2018, the Behavioral Specialist Consultant went through all other individuals¿ restrictive plans to ensure that all individuals¿ restrictions had a target date. All other restrictive plans included target date for individuals¿ restrictions.
3. All staff including the Behavioral Specialist Consultant will be trained by the CEO by 12/31/2018 on regulation 6400.195 e 5 to ensure that all individuals¿ restrictions in a restrictive plan have target dates. All staff will sign off on training signature paper.
4. The Behavioral Specialist Consultant will review all restrictive plans to ensure that all individual¿s restriction in a restrictive plan have target dates starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not include the name, address, relationship and telephone number of the person designated to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| 1. On 08/30/2018, the Program Specialist listed Medical Coordinator as emergency contact. Individual¿s mother is in jail and individual has no other relatives.
2. On 09/04/2018 the Program Specialist went through other individual¿s files to ensure that all other individuals have emergency contacts in their file. All other individual¿s had emergency contact listed in their file.
3. All staff including the Program Specialist will be trained by 12/31/2018 by Vice President on regulation 6400.211 b1 to ensure that all individuals have an emergency contact listed in their file. All staff will sign off on training signature paper.
4. The Program Specialist will review all individuals¿ files on a quarterly basis to ensure that each individual has an emergency contact in their file starting on 01/2019. |
10/11/2018
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not include the name, address and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| 1. On 08/30/2018 the Program Specialist listed the Medical Coordinator as the emergency contact to give medical consent. Individual¿s mother is in jail and individual has no other relatives.
2. On 09/04/2018 the Program Specialist went through other individual¿s files to ensure that all other individual had an emergency contact to give medical consent. All other individual¿s had emergency contact to give medical consent.
3. All staff including the Program Specialist will be trained by 12/31/2018 by the Vice President on regulation 6400.211 b3 to ensure that all individuals have an emergency contact to give medical consent in their file. All staff will sign off on training signature paper.
4. The Program Specialist will review all individuals¿ files on a quarterly basis to ensure that each individual has an emergency contact in their file to give medical consent starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.213(11) | REPEAT from 7/12/17 annual inspection: -Individual #1's 12/28/17 psychiatric appointment form lists Amoxicillin as an allergy. This allergy is not included on any other document in Individual #1's record.
-Individual #1's Individual Support Plan (ISP) includes a diagnosis of Anxiety. Individual #1's face sheet in the record did not include a diagnosis of Anxiety.
--Individual #1's supervision level in their restrictive procedure plan does not match their supervision level that is recorded in their ISP; "3:1 staffing for 2nd shift and 2:1 staffing for 1st and 3rd shift, staff need to be within hearing distance of the individual and 15 minutes eye sight checks to ensure his/her safety." | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | 1. On 8/30/2018, the administrative assistant updated the individual¿s demographics to reflect his current allergies.
2. On 09/04/2018, the administrative assistant reviewed all other individual¿s demographics to make sure that all were in compliance with regulation 6400.213.11. All demographics were updated to show current information on all of the individuals.
3. All staff including the administrative assistant will be trained by 12/31/2018 by quality compliance manager on regulation 6400.213.11 to ensure that all documentation is correct and up to date to include but not limited to allergies. All staff will sign off on training signature paper.
4. The administrative assistant will review all demographics on a quarterly basis to ensure compliance with regulation 6400.213.11 starting on 01/2019. |
10/12/2018
| Implemented |