| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.19 | Individual #2's May 2018 monthly review documentation indicated that he had 1 seizure during the month. A seizure log was not completed. | The facility shall maintain a record of an individual's illnesses, traumas and injuries requiring medical treatment but not inpatient hospitalization, and seizures that occur at the facility or while under the supervision of the facility. | On 9/28/18 the Program Specialist (PS) reviewed individual #2's daily documentation for the month of May, he did not have a seizure, the May monthly has a documentation error. No seizure log was needed for the month of May. The PS has corrected the documentation error, and resent the May monthly to individual #2 and his team. The PS and Administrative Assistant (AA) have reviewed the current (September) monthly reports on 10/8/18 to ensure all data is correct, using the record review checklist.
A staff meeting was held on 10/10/18, the results of the inspection and POC was reviewed with all staff. The CEO will review 50% of the PS reports on a quarterly bases, using the record review checklist This will start on 12/1/18 to ensure all documentation is correct. Individual #2's monthly report is attached for review, as is the record check list. |
09/28/2018
| Implemented |
| 2380.83(a) | The written emergency evacuation plan did not include individual responsibilities or means of transportation to the emergency relocation site. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency. | On 10/8/18 the written emergency evacuation plan was reviewed by the CEO, it has been updated to include individual and staff responsibility, means of transportation and emergency shelter location and an evacuation diagram giving direction in case of an emergency. A staff meeting was held on 10/10/18, the results of the inspection and POC was reviewed with all staff. The Administrative Assistant (AA) is reviewing all policies starting on 10/2/18 to ensure all polices/plans meet all regulation and information is correct following all the regulations. The completion date of policy review is 10/15/18. The CEO will review ALL policy/plans on a quarterly bases, starting on 12/1/18f to ensure all documentation is correct following all regulations. The updated emergency evacuation plan is attached for review. |
10/08/2018
| Implemented |
| 2380.84 | REPEATED VIOLATION -- 9/12/17. A fire safety inspection was last completed on 8/31/17. | The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | On 9/28/18 the Administrative Assistant (AA) called Keystone Inspection Agency to schedule the overdue fire safety inspection. This inspection was completed on the center on 9/28/18 and no violations were found. On 9/28/18 the AA also scheduled next year¿s inspection for 9/20/19. The CEO will be contacting Keystone in August 2019 to confirm the 9/20/2019 appointment. Once the 9/20/19 inspection is complete, the AA will schedule the 2020 inspection to assure no inspection is missed. The CEO will also confirm the 2020 inspection the month before. Going forward this is the protocol that the CEO will follow for all scheduled inspections. A staff meeting was held on 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones. |
09/28/2018
| Implemented |
| 2380.89(g) | The fire drill log did not indicate if all individuals evacuated to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | On 10/01/2018 the CEO reviewed the fire drill log. The log has been updated to include a Yes or No question to indicate if all individuals evacuated to the designated meeting place. This updated fire drill log has been reviewed with all staff during the meeting that was held on 10/10/18, the entire results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones.
The CEO will review ALL policy/plans on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct following the regulations. The updated emergency evacuation plan is attached for review. |
10/01/2018
| Implemented |
| 2380.91(a) | REPEATED VIOLATION - 9/12/17. Individual #3 was admitted to the program on 6/4/18. Fire safety training was not completed until 6/14/18. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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, and smoking safety procedures if individuals smoke at the facility. | On 10/15/18 the Administrative Assistant (AA) created a new admission check list to help ensure that no trainings or requirements upon admission are missed. The new admission check list is attached for review. The CEO will review ALL policy/plans on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct based on the regulations. The CEO and AA will be reviewing all individuals¿ files starting on 10/15/18 for any discrepancies¿, using the record review check list, this review is scheduled to be completed by 11/15/18. A staff meeting was held on 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones. |
10/15/2018
| Implemented |
| 2380.111(c)(7) | Individual #4's 1/31/18 physical exam did not include his current medication regimen. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | A request was made to individual #4's doctor and his residential provider on 10/2/18 to have the physical updated to include current medication regimen. The physical was returned to us to include the updated medication list and it has been copied and placed with the physical in his file and also in the medication log. The Program Specialist (PS) along with the LPN will review all physicals that come into the center to make sure the form is filled out in its entirety and all required attachments are available. The Administrative Assistant (AA) and CEO have started reviewing all files on 10/15/18, for discrepancies¿, using the record review check list, this review is schedule to be completed by 11/15/18. The CEO will also be reviewing all individuals¿ files on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct and all required paperwork is present. During the staff meeting that was held on 10/10/18, the entire results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones. Individual #4¿s updated physical and medication list is attached for review. |
10/05/2018
| Implemented |
| 2380.111(c)(10) | REPEATED VIOLATION - 9/12/17. Individual #4's 1/31/18 physical exam did not include information pertinent to diagnose in case of an emergency. The field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A request was made to individual #4's doctor and his residential provider on 10/2/18 to have the physical updated to include information pertinent to diagnose in case of an emergency. The physical was returned to us to include the required information. The Program Specialist (PS) along with the LPN will review all physicals that come into the center to make sure the form is filled out in its entirety and all required fields are completed. The Administrative Assistant (AA) and CEO have started reviewing all files on 10/15/18, for discrepancies¿, using the record review check list, this review is schedule to be completed by 11/15/18. The CEO will also be reviewing all individuals¿ files on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct. During the staff meeting that was held on 10/10/18, the entire results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones. Individual #4¿s updated physical is attached for review. |
10/05/2018
| Implemented |
| 2380.124(a) | REPEATED VIOLATION - 9/12/17. Individual #1 was administered Lorazepam .5mg on 7/19/18 and 6/21/18. There was no time of administration on the log. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | On 10/10/18, the entire results of the inspection and POC was reviewed agency wide to correct all current issues and prevent future ones. Sunny Days DHS medication trainer retrained the staff on the proper protocol when administering medication, this included, the name of the person administering the medication, the time and the date the medication was given. The LPN and the DHS medication trainer will be reviewing all medication logs on a weekly basis, this was started on 10/8/18, any discrepancies are brought to the individual to be corrected and also brought to the CEO for further review. The medication log has also been updated to make more space for all required information. The CEO will be reviewing all medication logs monthly to ensure all data is accurate and complete using the medication log check list. The first review of the medication logs will be on 10/31/18. The medication log and the training sign in sheet is attached for review. |
10/10/2018
| Implemented |
| 2380.128(a) | Staff #1 and #3 transferred from another agency with medication administration training completed, however there was no documentation of the training. Sunny days did not complete the practicum summary before allowing Staff #1 and #2 to pass medications. | A staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | On 9/28/19 a request was made to Staff #1's other agency to obtain her medication training record and medication observation packets since she is still currently working and being observed at her over agency. Staff #1's complete med packet has been obtained, as of 10/22/18, a copy is available at the main office, and she has been observed passing medication 4 times at the center by the DHS medication administration trainer, and is now able to pass medication at Sunny Days. Observation packets are available at the main office.
Sunny Days DHS Medication Trainer has started the process to retrain staff #2 on 10/2/18. Staff #2 will finish completion of training by 10/31/18. During this training time. the LPN, staff #1 and DHS medication trainer will be passing all medication at Sunny Days.
The CEO and Administrative Assistant will be reviewing all new employees¿ credentials upon first day of employment. A new staff hire check list has been implemented and will be followed to assure all copies of required certificates, trainings, etc are obtained. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. A copy of the new hire check list is attached for review. (there was not a staff#3) |
10/31/2018
| Implemented |
| 2380.132(3) | The bottom of the menu indicated "menu subject to change". Staff #3 indicated that if there aren't enough individuals that show up to program, they may serve a different meal that day. The change in meal occurs in the morning and is not posted one program day prior to the menu date as required in 2380.132(2). | If the facility provides or arranges for meals for individuals, the following requirements apply: Menus shall be followed. | On 10/2/18 the Administrative Assistant (AA) and Cook updated the October menu, and removed the subject to change section. The CEO created a protocol policy on 10/1/18 to address if and when a menu needs to change, what will happen. This policy was distributed to all individuals on 10/3/18. The AA and Cook will continue to work together to ensure that all future menus contain all required food groups. The CEO will approve all menu¿s starting 10/31/18 for content. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The updated Menu and the protocol policy are attached for review. |
10/03/2018
| Implemented |
| 2380.132(6) | According to the menu, On 8/7/18 the facility was serving soup and sandwiches, chips, fruit. Protein and vegetables weren't offered. On 8/9/18 the facility served mac and cheese, stewed tomatoes, fruit. Protein wasn't offered. On 8/17/18, the facility served egg salad on multigrain roll, chips, fruit. A vegetable wasn't offered. On 8/28/18, the facility served fish sticks/chicken nuggets, tater tots, fruit. A vegetable wasn't offered. On 8/30/18, the facility served hot dogs with bun, beans, fruit. A vegetable wasn't offered. The same menu items are offered every month. Every month, food groups are missing from meals. | If the facility provides or arranges for meals for individuals, the following requirements apply: Each meal served shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless medically contraindicated for an individual. | On 10/2/18 the Administrative Assistant (AA) and Cook updated the October menu to show what food group each food item listed represents. The October menu was then reviewed by the CEO and distributed to all individual on 10/3/18. The AA and Cook will continue to work together to ensure that all future menus contain all required food groups. The CEO will approve all menu¿s starting 10/31/18 for content. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. |
10/03/2018
| Implemented |
| 2380.155(e)(5) | Individual #1's restrictive plan did not include a target date for achieving the behavioral outcome. | The restrictive procedure plan shall include: A target date for achieving the outcome. | Individual #1's restrictive plan was reviewed and was rewritten on 10/5/18 to update the plan to have a target date for achieving the outcome. The PS has scheduled with the HRC on 10/2/18 to have the new restrictive plan reviewed and approved at the 11/13/18 meeting. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The current restrictive plan was also reviewed with all staff, and will be followed until the new plan is approved. All staff will be retrained on the new plan once approved within 5 days of the approval. The CEO will be reviewing the restrictive plan in house monthly, using the record review check list and will go before the HRC committee every six months, or sooner if the plan needs revised. The CEO will also be reviewing all policies and plans quarterly staring on 12/1/18. |
10/05/2018
| Implemented |
| 2380.155(e)(8) | Individual #1's restrictive plan did not include the name of person or position responsible for documenting progress with plan. | The restrictive procedure plan shall include: The name of the staff person or staff position responsible for monitoring and documenting progress with the plan. | Individual #1's restrictive plan was reviewed and was rewritten on 10/5/18 to clarify that the Program Specialist (PS) is the person that is responsible for documentation and progress of the plan. The PS has scheduled with the HRC on 10/2/18 to have the new restrictive plan reviewed and approved at the 11/13/18 meeting. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The current restrictive plan was also reviewed with all staff, and will be followed until the new plan is approved. All staff will be retrained on the new plan once approved with in 5 days of the approval. The CEO will be reviewing the restrictive plan in house monthly, using the record review check list and will go before the HRC committee every six months, or sooner if the plan needs revised. The CEO will also be reviewing all policies and plans quarterly staring on 12/1/18. |
10/05/2018
| Implemented |
| 2380.173(9) | REPEATED VIOLATION - 9/12/17. Individual #2's 2/28/18 seizure protocol indicated to administer diazepam rectal gel, 5mg for more than 3 seizures in 90 minutes. Second dose may be given in 6 hours after first does for any seizure lasting more than 2 minutes. If continues to have seizure after second dose, then must go to ER. Also any seizure activity associated with a fever (more than 100 degrees) needs to be seen in the ER. The Diazepam medication label indicated Diazepam to administer 5mg rectally if needed for seizures lasting greater than 5 minutes, second dose no sooner than 6 hours.
Individual #3's ISP indicated no allergies. Her physical exam indicated morphine.
Individual #1's assessment indicated diagnosis of PICA. This was not contained on the physical. Her assessment indicated diagnosis of impulse control disorder and GERD. This was not on the physical.
Individual #1's ISP included allergies to Tegretol and Vimpat. The physical indicated Augmentin as an allergy.
Individual #4's ISP indicated his supervision ratio at day program is 1:2-1:6. His ISP reviews indicated 1:4 and his assessment indicates 1:6 for day program.
Individual #2's record included a seizure protocol signed on 2/28/18 that indicates "administer diazepam rectal gel 5mg for more than 3 seizures in 90 minutes. Second dose may be given in 6 hours after first does for any seizure lasting more than 2 minutes. If continues to have seizure after second dose, then must go to ER. Also any seizure activity associated with a fever (more than 100 degrees) needs to be seen in the ER." His ISP listed "Diazepam rectal gel, 10mg as needed for a seizure lasting greater than 5 minutes; 5mg rectally, give 2nd dose no sooner than 6 hours." His medication list created on 1/23/18 listed diazepam 10mg rectal gel, administer 5mg rectally if needed for seizures lasting greater than 5 minutes. Second dose no sooner than 6 hours.
Individual #2's 3/23/18 assessment indicated that he continues to have seizures regularly. He sometimes goes a few days at a time with no seizures, however when he does have one he is likely to have more. He often requires several doses of Ativan to stop his seizure activity once they start. His ISP and seizure protocol indicate he is prescribed Diazepam rectal gel for seizures, not Ativan. His assessment did not indicate he takes prn Diazepam at day program for seizures.
Individual #2's 2018 physical indicated he should be on a mechanical soft diet. His ISP indicates a moist mechanical soft food with thin liquids. He is to be positioned upright for eating and drinking. He should take 1 bite/sip at a time and alternate between bites/sips. Liquids should be put in a sports bottle/sippy cup to decrease rate and volume and the risk of choking, but he should not use straws. Bowls and cups should be placed on a non-skid mat to increase ease of self-eating."
Individual #2 attended the program 5 days per week. His ISP indicated that he attends a Skills ATF Monday, Wednesday, Friday and Sunny Days and Tuesday and Thursday. | Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The Program Specialist (PS) sent an email to individuals #3's SC on 10/10/18 to update her allergies list.
Track changes have been sent to individuals #2's SC on 10/10/18 by the PS to update content in the ISP, to address his frequency at the day center being incorrect, to change his need/wiliness for a sports bottle and mat to be used during eating. The current ISP will be followed and we will continue to offer the sports cup and use the mat until the ISP has been updated, refusal of the bottle will be documented in his daily log by the DSW¿s. The CEO contacted individual #2¿s residential staff on 10/2/18 to obtain a new label for his Diazepam that matches his seizure protocol on file. The new label for his Diazepam was received in the center on 10/5/18 and is located in the locked medication cart. The PS has reviewed his assessments and updated it for current content and content that pertains to the day program so that there is no confusion between day and home. The updated assessments are attached for review.
The PS sent a request to #1's SC to update her medications and allergies in the ISP. The LPN will review her April 2019 physical to assure all allergies, medications and diagnose that are present in the ISP are current and present on the physical. If the doctor disagrees with any diagnoses, allergies or medication in the ISP, the LPN will discuss the findings with the PS and the PS will contact individual #1¿s SC to address track changes.
On 10/2/18 the Program Specialist (PS) reviewed individual #4's assessment. The assessment was updated to make the correction of his ratio in the center to match the ratio listed in his ISP. The assessment was resent to individual #4 and his team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present and accurate, she will utilize the ISP and record review check list to assist with data.
It is the PS responsibility to review all files and protocol in the ISP. The PS and the Administrative Assistant (AA) have started to review all assessments, using the record review check list, starting on 10/15/18 to be concluded by 11/15/18, the findings will then be brought to the CEO for review and changes made and updated as needed. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct and accurate, also using record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. |
10/22/2018
| Implemented |
| 2380.181(a) | REPEATED VIOLATION - 9/12/17. Individual #4 admitted to the program on 4/3/18 and his assessment was completed on 6/5/18. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Individual #4's assessment was not signed until he returned to day programming, the CEO has retrained the Program Specialist (PS) on this regulation on 10/5/18. The PS will now sign all assessments on the date they are completed and not the date the individual returns to the center. The PS will review the assessment with the individual on the date they return. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18 they will utilize the record review check list. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct, dated and signed also using the review check list to ensure accuracy. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. |
10/10/2018
| Implemented |
| 2380.181(e)(7) | Individual #1's 7/16/18 assessment and Individual #4's 6/5/18 assessment did not include the ability to move away 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. | On 10/2/18 the Program Specialist (PS) reviewed individuals #1 and individual #4¿s assessments, using the record review check list. The assessments were updated to include their ability to move away from a heat source, which was missing in the assessment. The updated assessment was resent to both individual¿s team members on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present using the check list for accuracy. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 and it was correct for all content. The PS and the Administrative Assistant (AA) have started to review all assessments, utilizing the record check list, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct, the CEO will also use the record check list during reviews. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #1and #4's assessment are attached to show the updated form and the individual¿s ability to move away from a heat source. |
10/10/2018
| Implemented |
| 2380.181(e)(13)(i) | Individual #3's 8/2/18 assessment did not include current level of health. There was no section in the assessment to address this requirement. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. | On 10/2/18 the Program Specialist (PS) reviewed individual #3¿s assessments, using the record review check list. Her assessment was updated to include her current health, which was missing in the assessment. The updated assessment was resent to her and her team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present using the check list for accuracy. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 and it was correct for all content. The PS and the Administrative Assistant (AA) have started to review all assessments utilizing the record review check list, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct also using the check list for accuracy. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #3¿s assessment is attached to show the updated form and health section. |
10/10/2018
| Implemented |
| 2380.181(e)(13)(iv) | Individual #3's 8/2/18 assessment and Individual #4's 6/5/18 did not include current level of socialization. There was no section in the assessment to address this requirement. | 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. | On 10/2/18 the Program Specialist (PS) reviewed individual #3 and #4's assessments, using the record review check list. Both assessments were updated to include their level of socialization, which was missing in the assessment. The updated assessments were resent to both individual¿s team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present and to use the record review check list to assist in this review. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 and it was correct for all content. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct, the CEO will also use a record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #3 and #4¿s assessments are attached to show the updated form and socialization section. |
10/10/2018
| Implemented |
| 2380.181(e)(13)(v) | REPEATED VIOLATION - 9/12/17. Individual #3's 8/2/18 assessment and Individual #4's 6/5/18 did not include current level of recreation. There was no section in the assessment to address this requirement. | 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. | On 10/2/18 the Program Specialist (PS) reviewed individual #3 and #4's assessments, using the record review check list. Both assessments were updated to include their progress and growth in the area of recreation, which was missing in the assessment. The updated assessments were resent to both individual¿s team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present using the check list. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 and it was correct for all content. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct and accurate, the CEO will use the record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #3 and #4¿s assessments are attached to show the updated form and recreation section. |
10/10/2018
| Implemented |
| 2380.181(e)(13)(vi) | REPEATED VIOLATION - 9/12/17. Individual #3's 8/2/18 assessment and Individual #4's 6/5/18 did not include current level of community integration There was no section in the assessment to address this requirement. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | On 10/2/18 the Program Specialist (PS) reviewed individual #3 and #4's assessments using the record review check list. Both assessments were updated to include the community integration section that was missing. The updated assessments were resent to both individual¿s team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 using the check list. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct, the CEO will also be using the record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #3 and #4¿s assessments are attached to show the updated form and community integration section. |
10/10/2018
| Implemented |
| 2380.181(e)(14) | Individual #3's 8/2/18 assessment did not include her knowledge of water safety or ability to swim. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | On 10/2/18 the Program Specialist (PS) reviewed individual #3's assessment. The assessment was updated to include her knowledge of water safety and ability to swim. The updated assessment was resent to her and her team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present. The PS has updated all templates to ensure all parts of the assessment are present, the CEO reviewed the template on 10/3/18 using the record review check list. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18 using the check list. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct also using the record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #1¿s assessment is attached to show her knowledge of water and ability to swim. |
10/10/2018
| Implemented |
| 2380.181(f) | REPEATED VIOLATION - 9/12/1. Individual #4's 6/5/18 assessment was not sent to his parents, residential facility or behavior support person. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | On 10/2/18 the Program Specialist (PS) reviewed individual #4's assessment. The assessment was updated to include his parents and his residential facility, individual #4 does not have a BSS. The assessment was resent to the team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present. The PS and the Administrative Assistant (AA) have started to review all assessments, using the record review check list, starting on 10/15/18 to be concluded by 11/15/18. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct also using the record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #4¿s assessment is attached to show that the entire team has been included and sent the assessment. |
10/10/2018
| Implemented |
| 2380.183(3) | REPREATED VIOLATION -- 9/12/17. Individual #4's ISP does not include a method of evaluation used to determine progress on his ISP outcome of socialization/program involvement. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | On 10/8/18 the Program Specialist (PS) sent track changes to individual #4's SC changing the wording of the outcome for him, this was done to have a more defined method to evaluate the progress of his socialization/program involvement outcome. The CEO will review all individual¿s outcomes quarterly with the PS to ensure they are written correctly and that they still fit the individuals needs and wants. This will begin on 12/1/18. Currently the PS and Administrative assistant have started a review of all current ISP¿s on 10/15/18 to ensure content is applicable and correct. They will conclude this on 11/15/18 and report findings to the CEO and update all individuals SC¿s if content needs changed. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email the PS sent to individual #4¿s SC requesting the change in outcome wording is attached for review. |
10/24/2018
| Implemented |
| 2380.183(4) | REPEATED VIOLATION - 9/12/17. Individual #3 required 1:1 supervision while at day program. The ISP does not include a plan to reduce the intensive staffing. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | On 10/09/18 the program specialist reviewed individual #3's ISP, an email was sent to her supports coordinator (SC) asking for her to add our plan/explanation why we will not be reducing the intensive staffing. The CEO and the Administrative Assistant (AA) have started to review all ISP¿s for content, starting on 10/15/18 to be concluded by 11/15/18 each section of the ISP will be reviewed. The Program Specialist will then be updated weekly on any discrepancies that the CEO or AA find so that the PS can notify the SC to make needed changes. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email the PS sent to individual #3¿s SC requesting an addition of the intensive staffing section is attached for review. |
10/24/2018
| Implemented |
| 2380.183(5) | REPEATED VIOLATION - 9/12/17. Individual #3's ISP did not include her SEEN plan. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | On 10/09/18 the program specialist reviewed individual #3's ISP, an email was sent to her supports coordinator (SC) to request the SEEN plan for Sunny Days be added to the ISP. The CEO and the Administrative Assistant (AA) have started to review all ISP¿s for content, starting on 10/15/18 to be concluded by 11/15/18, all sections of the ISP will be reviewed. The Program Specialist will then be updated, weekly on any discrepancies that the CEO or AA find so that the PS can notify the SC to make needed changes. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email to the SC requesting the SEEN plan be added is attached for review. |
10/24/2018
| Implemented |
| 2380.183(7)(i) | REPEATED VIOLATION - 9/12/17. Individual #3's ISP did not include her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Vocational programming. | On 10/09/18 the program specialist reviewed individual #3's ISP, an email was sent to individual #3's supports coordinator (SC) to request the proper information be added to the ISP in the section to express her potential to advance in vocational programming. The CEO and the Administrative Assistant (AA) have started to review all ISP¿s for content, starting on 10/15/18 to be concluded by 11/15/18, each section of the ISP will be reviewed. The Program Specialist will then be updated, weekly on any discrepancies that the CEO or AA find so that the PS can notify the SC. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email to the SC requesting the update to the ISP is attached for review. |
10/24/2018
| Implemented |
| 2380.183(7)(iii) | REPEATED VIOLATION 9/12/17. Individual #3's ISP did not include her potential to advance in competitive employment | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. | On 10/09/18 the program specialist reviewed individual #3's ISP, an email was sent to individual #3's supports coordinator (SC) to request the proper information be added to the ISP in the competitive employment section. The CEO and the Administrative Assistant (AA) have started to review all ISP¿s for content, starting on 10/15/18 to be concluded by 11/15/18, each section of the ISP will be reviewed. The Program Specialist will then be updated, weekly on any discrepancies that the CEO or AA find so that the PS can notify the SC. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email to the SC requesting the update to the ISP is attached for review. |
10/24/2018
| Implemented |
| 2380.185(b) | REPEATED VIOLATION - 9/12/17. Individual #1's restrictive behavior plan indicated when Individual #1 is hurting herself or someone else, she will be given 1) verbal prompt to calm down. 2) pressure hold no longer then 5 seconds if verbal prompt did not stop behavior. 3) 5 minute time out in quiet area with 1:1 staff for 5 minutes.
On 8/14/18 - staff documented Individual #1 pulled staff's hair. She was put on time out. A verbal prompt was not given. A pressure hold was not utilized as documented in the plan. On 8/17/18- staff documented Individual #1 hitting herself in the head. The plan was not implanted. On 8/20/18, Individual #1 slapped staff. It was documented that she was pulled away from tv back to her chair. This was not part of the plan and the plan was not implemented. On 8/21/18 - Individual #1 was biting her hand/hitting herself. She was asked her to stop. The plan was not implemented. On 8/21/18 Individual #1 kicked staff. She was sent to time out. a verbal prompt was not given. On 8/2818, Individual #1 was hitting her head/bit hand. The plan was not implemented.
Individual# 3's ISP indicated that he is prescribed Proair HFA 90mcg, use 2 puffs every 4 hours as needed for wheezing/shortness of breath. This medication was not available for him at the facility.
Individual #4's ISP indicated he should be repositioned frequently and will be encouraged to get out of his wheelchair for periods of time and repositioned to help prevent further breakdown. His ISP indicated he required a wheelchair for mobilization with a gel cushion on it to help prevent sores. There is no documentation to indicate that he was repositioned (or offered to) throughout the day. There was not a gel cushion on his chair.
Individual #2's ISP indicated moist mechanical soft foods with thin liquids. He was to be positioned upright for eating and drinking. He should take 1 bite/sip at a time and alternate between bites/sips. Liquids should be put in a sports bottle/sippy cup to decrease rate and volume and the risk of choking, but he should not use straws. Bowls and cups should be placed on a non-skid mat to increase ease of self-eating. Individual #2 was using a regular cup without a lid during lunch and there was not a mat under his plate.
Individual #4's residential provider faxed an order issued on 4/3/18 to Sunny Days to use Sensicare, apply to buttocks with every brief change. This was not available at the facility. | The ISP shall be implemented as written. | Individual #1's restrictive plan was reviewed and was rewritten on 10/5/18 to clarify the order of the steps and when to implement them. The Program Specialist (PS) has scheduled with the HRC on 10/2/18 to have the new restrictive plan reviewed and approved at the 11/13/18 meeting. The current restrictive plan was also reviewed with all staff on 10/10/18 and will be followed until the new plan is approved. All staff will be retrained on the new plan once approved, within 5 days of the approval. The CEO will be reviewing the restrictive plan in house monthly, using the record review check list for restrictive and will go before the HRC committee every six months, or sooner if the plan needs revised.
Individual #4's order for sensicare was D/C on 9/28/18 a copy is attached. The Program Specialist (PS) contacted residential on 9/28/18 to ensure any medication that needs to be administered at the center is available to us, at this time, no other medication is needed during day programming. Individual #4 is in the process of getting a new chair and his gel pad has been removed, per the residential staff. It is stated in the ISP that individual #4 refuses to be repositioned or moved in his chair, at the 10/10/18 staff meeting all DSW¿s were retrained to document when they ask him if he refuses or if he is re-positioned. This will be documented in his daily logs.
Individual #3 does not have an order for Proair HFA.
Individual #2 has an order for Proair HFA and the Program Specialist has resent an email to his residential program specialist on 10/22/18 requesting that the inhaler be sent to day programming to ensure he has the medication if it is needed. Track changes have been sent to individuals #2's SC on 10/10/18 by the PS to update content in the ISP, to address his need/wiliness for a sports bottle and mat to be used during eating. The current ISP will be followed and we will continue to offer the sports cup and use the mat until the ISP has been updated, refusal of the bottle will be documented in his daily log by the DSW¿s All staff were retrained on this during the 10/10/18 staff meeting.
The PS will review all ISP's to ensure proper changes are made and the ISP in being implemented as written. Currently the PS and Administrative Assistant have started a review of all current ISP¿s on 10/15/18 to ensure content is applicable and correct. They will conclude this review on 11/15/18 and report any and all findings to the CEO and update all individuals SC¿s if content needs changed, they will be using the record check list. The CEO will also be reviewing all policies and plans quarterly starting on 12/1/18 to ensure accuracy and content. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones from occurring. |
10/22/2018
| Implemented |
| 2380.186(c)(1) | Individual #3s 9/6/18 ISP review did not include progress toward the socialization outcome. Individual #1's 8/3/18, 5/3/18, 2/1/18, ISP review did not include progress toward the ISP outcome of meaningful activities/community integration. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | On 10/20/18 the Program Specialist (PS) resent track changes to individual #3's SC changing the wording of the outcome for her, this was done to have a more defined method to evaluate the progress of her socialization outcome. Once this change has been made by the SC we will able to properly document on individual# 3¿s outcome. The Program Specialist (PS) also resent track changes to individual #1¿s SC changing the wording of her meaningful activities/community participation outcome. The CEO will review all individual¿s outcomes quarterly with the PS to ensure they are written correctly and that they still fit the individuals needs and wants. We will utilize part of the record check list. This will begin on 12/1/18.
Currently the PS and Administrative assistant have started a review of all current ISP¿s on 10/15/18 to ensure content is applicable and correct. They will conclude this on 11/15/18 and report findings to the CEO and update all individuals SC¿s if content needs changed, also using the record check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. The CEO will be holding another staff training on 10/24/8 to review the ISP¿s with staff, to outline, what needs to be present in the ISP, to ensure during staff ISP reviews that they are aware of what to flag if something is missing and who to report it to. The email the PS sent to individual #3 and #1¿s SC requesting the change in outcome wording is attached for review. |
10/24/2018
| Implemented |
| 2380.186(c)(2) | REPEATED - 9/12/17. Individual #3's 9/6/18 ISP review did not review her SEEN plan or 1:1 staffing ratio. Individual #2's ISP included a seizure protocol and his record included a seizure log from 4/19/18 at 10:26am. The 4/23/18 ISP review that reviewed the period from 1/21/18-4/20/18 did not include a review of this seizure.
Individual #2's May 2018 monthly documentation indicated he had one seizure during the month. His 7/24/18 ISP review did not review this seizure. Individual #2's 10/24/17, 1/24/18, 4/23/18 ISP reviews did not review any community outings. The 7/24/18, 4/23/18, 1/24/18, 10/24/17 ISP reviews did not review his SEEN plan | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Individual #3's 9/6/18 ISP review has been updated by her Program Specialist (PS) on 10/9/18 to review her SEEN plan and her 1:1 staffing. The updated plan was review with the individual and also sent to the team on 10/10/18.
Individual #2's 4/23/18 ISP review has been updated on 9/28/18 to document his seizure from 4/14/18 (it was not 4/19/18) The updated plan was reviewed with the individual on 9/28/18 and was also resent to the team on 9/28/18. On 9/28/18 the Program Specialist (PS) reviewed individual #2's daily documentation for the month of May, he did not have a seizure, the May monthly has a documentation error. No seizure log was needed for the month of May. The PS has corrected the documentation error, and resent the May monthly to individual #2 and his team. His most current reviews have been updated to include community outing if any and also his SEEN plan.
The PS and the Administrative Assistant (AA) have started to review all assessments, using the record check list starting on 10/15/18 to be concluded by 11/15/18, the findings will then be brought to the CEO for review and changes made and updated as needed. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct also using the record check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. |
10/10/2018
| Implemented |
| 2380.186(e) | REPEATED VIOLATION - 9/12/17. Individual #4's residential facility and behavior support specialist did not receive the option to decline his ISP review information. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | On 10/2/18 the Program Specialist (PS) reviewed individual #4's assessment, using the record review checklist. The assessment was updated to include the section where his residential facility can have the option to decline his ISP reviews, this section was cut off from his original assessment, individual #4 does not have a BSS. The assessment was resent to the team on 10/5/18. It is the PS responsibility to review all assessments for content and assure all parts of the assessment are present. The PS and the Administrative Assistant (AA) have started to review all assessments, starting on 10/15/18 to be concluded by 11/15/18, the findings will then be brought to the CEO for review and changes made and updated as needed. The CEO will review 50% of the PS¿s reports on a quarterly bases, starting on 12/1/18 to ensure all documentation is correct, also using record review check list. On 10/10/18, the results of the inspection and POC was reviewed agency wide to correct all current issues and educate all staff to help prevent future ones. Individual #4¿s assessment is attached to show that his residential facility does have the option to decline his ISP review. The record review check list is attached for review. |
10/05/2018
| Implemented |