| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Initial fire safety training not found in record for staff member#1 at inspection. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Edwards Hope Corporation Program Specialist and Program Director will follow the Office of Developmental Programs approved list of trainings to be completed during the orientation week. for example, fire safety. There will be sign off sheet indicating each training and a sign off sheet at the end of the orientation week. Staff #1 had this initial orientation 8/19/21. |
08/30/2022
| Implemented |
| 6400.46(j) | Orientation training not found in record at inspection for staff member #1. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Edwards Hope Corporation Program Specialist and Program Director will follow the Office of Developmental Programs approved list of trainings to be completed during the orientation week. for example, Department policies on intellectual disabilities principles, QM Plan, etc There will be sign off sheet indicating each training and a sign off sheet at the end of the orientation week indicating
Orientation Trainings. |
08/30/2022
| Implemented |
| 6400.67(a) | The dresser(s) located in Individual#1's bedroom are missing knobs, making it difficult for the individual to open the drawers. | Floors, walls, ceilings and other surfaces shall be in good repair. | All staff were trained on recognizing and reporting missing, damaged, broken furniture to their supervisor. The house manager will use the weekly checklist to document all property destruction that it will be fixed in a timely manner. The Program director will use a monthly checklist to document all property destruction and ensure it is fixed/replaced asap. |
08/05/2022
| Implemented |
| 6400.104 | Notification to the fire department dated 7/15/22 states there are 3 individuals in the home- however, there were 2 individuals residing in this home at inspection. This letter is not current. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Edwards Hope Corporation CEO will meet quarterly with the Program Director to go over areas of compliance with all paperwork. The guidelines for annual licensing will be used as a check list. |
09/30/2022
| Implemented |
| 6400.112(c) | Fire drill dated 7/9/21 did not include the time of the drill. | 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. | All staff were retrained on their responsibilities of filling out all areas of the fire drill and filling it out accurately. |
08/30/2022
| Implemented |
| 6400.112(e) | Fire drills dated, 7/9/21,12/2/21, 3/26/22-did not indicate sleep/wake fire drills. | A fire drill shall be held during sleeping hours at least every 6 months. | All staff were retrained on their responsibilities of filling out all areas of the fire drill and filling it out accurately. The Program Director was retrained. |
10/30/2022
| Implemented |
| 6400.141(c)(6) | Per Annual Physical Exam Form dated 10/18/2021 Individual#1 is not current with TB screening; last screening was given 07/22/2020 and read 07/24/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Edwards Hope Corporation plans on continuing compliance with 6400 regulations. Individual #1 was a new admittance and having to explain the regulations to the doctor took some time and understanding. Individual #1 has a date for his physical 10/12/2022 and we see no further concerns. |
10/13/2022
| Implemented |
| 6400.141(c)(9) | The physical examination form dated 10/18/2021 did not indicate if a test for prostate examination was completed, individual#1 is over 40yrs old. This portion of the exam was left blank. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Edwards Hope Corporation house manager will assist the individual on all medical appointment to make sure all areas of the physical is filled out and to make sure all instructions and questions by the nurse are answered. The nurse will review the physical asap to make sure all areas are completed by the doctors before filing away in the individual's charts. |
08/30/2022
| Implemented |
| 6400.141(c)(13) | Based on the Physical Form dated 10/18/21, the Allergies section was left blank, and it could not be determined if individual#1 has any allergies. | The physical examination shall include: Allergies or contraindicated medications. | Edwards Hope Corporation house manager will assist the individual on all medical appointment to make sure all areas of the physical is filled out and to make sure all instructions and questions by the nurse are answered. The nurse will review the physical asap to make sure all areas are completed by the doctors before filing away in the individual's charts. |
08/30/2022
| Implemented |
| 6400.142(c) | Dental Care follow-up for Individual#1 was not made or kept, follow-up date was to be 02/2022. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | A copy of the appointment calendar will be kept in the homes to remind all staff of appointments. A new dental date is set for November 2022. The wait is because individual #1 has to be sedated and seen by a dental office approved by his insurance. |
11/30/2022
| Implemented |
| 6400.144 | The Diabetic logged for Individual#1 is not being logged correctly and has no structure. Staff is not logging the correct readings from the meter and some days logging numbers that is not on the meter. | 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.
| All staff were retrained on the new diabetic log and using the diabetic machine. |
08/30/2022
| Implemented |
| 6400.168(d) | Medication training for staff member #1 not found in record at inspection. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Edwards Hope Corporation will follow the Office of Developmental Programs approved list of medical trainings/trainings to be completed and to remain in compliance. Staff #1 training was completed 2018 and his last review date was 4/2020. |
08/30/2022
| Implemented |
| 6400.181(a) | An annual assessment was not completed for Individual#1, last assessment is dated 07/29/2021 Current assessment was not provided at inspection. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The program Specialist will email a copy of the assessment to the Program Director in order to have an updated copy saved on the cloud. A copy of the assessment will be uploaded to the individual's online profile. This is a private network that is accessible to managers. |
08/30/2022
| Implemented |
| 6400.217 | Written consent for individual#1 was not completed annually, 2021 consents were not provided at time of inspection. | 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.
| Edwards Hope Corporation Program Specialist and Program Director will use the checklist to make sure all individual's sign their consent packet annually. |
08/30/2022
| Implemented |
| 6400.24 | Criminal background check not found in record for staff members #1, and #2 at inspection. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Edwards Hope Corporation Program shall follow the statues regulations and local ordinances of the Federal and State Government. All potential employees will be given a provisional hire and a criminal background check at the time of being hired. They will not be allowed to start until the clearances return with no listed Federal or State violations. |
08/30/2022
| Implemented |
| 6400.31(b) | A signed copy of Rights for Individual#1 was not completed annually, 2021 rights was not provided during the agency's annual inspection. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | The individual Rights is in the consent packet. The Program Specialist and Program Director will use the checklist to make sure all individual's sign their rights/consent packet annually. |
08/30/2022
| Implemented |
| 6400.51(a)(1) | Orientation training not found in record at inspection for staff member#1. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Edwards Hope Corporation Program Specialist and Program Director will follow the Office of Developmental Programs approved list of trainings to be completed during the orientation week. for example, fire safety. There will be sign off sheet indicating each training and a sign off sheet at the end of the orientation week indicating
Orientation Trainings. |
08/30/2022
| Implemented |