Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.46(e) | Direct Service Worker #1, date of hire 11/12/15, did not have training on the individual's rights within the 30 calendar days after initial employment or within the 12 months prior to initial employment. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | No longer employed as of 9/28/16. A full-time Training and Compliance Manager was hired and trained. The TCM Manager will conduct new hire orientation and train new employees on Individual¿s Rights, ODP¿s Principals and Values training have been added to the agency orientation as of 09/26/2016. Employees complete orientation prior to working with individuals.[At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.46(h) | There was not documentation showing that Direct Service Worker #1, date of hire 11/12/15 was trained before working with individuals in first aid techniques; therefore, compliance could not be measured. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | No longer employed as of 9/28/16. New Training Manager was trained and will review all employees training record and document on orientation form if necessary. Trained on tracking form and reviewed 6400 regulations. The TCM Manager will conduct med certification, First Aid/CPR, and all professional development training. She will tract all staff training as well as provide all required and needed training to all staff on an ongoing basis. All training will be accurately documented in employee files and reviewed by the Director of Operations. [At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.46(i) | Direct Service Worker #1's training in cardio-pulmonary resuscitation expired on 6-6-16. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | No longer employed as of 9/28/16. A full-time Training and Compliance Manager has was hired and trained. The TCM Manager will conduct med certification, First Aid/CPR, and all professional development training. She will tract all staff training as well as provide all required and needed training to all staff on an ongoing basis. All training will be accurately documented in employee files and reviewed by the Director of Operations. [At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.110(e) | The home has three stories. The smoke detectors on each floor of the home, which include a basement, first floor and second floor were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The Director of Operations purchased new smoke detectors in October and was installed by site supervisors. Wireless interactive connectable smoke alarms have been purchased for each level of the house (basement, first floor and second floor). [At least weekly for 1 month and continuing monthly thereafter, a designate staff person shall check all smoke detectors in all community homes to ensure they are operable, interconnected and audible as required. Documentation of checks shall be kept and reviewed by the director of operations at least quarterly. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.111(a) | The fire extinguishers located in basement and the attic of the home had 1-A 10 BC ratings. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The Director of Operations purchased new fire extinguishers in October and they installed by site supervisors. A 2-A rating fire extinguisher has been purchased for the second floor and basement and is scheduled for delivery. Invoice is attached. [Immediately, and at least quarterly a designated management staff person shall check all fire extinguishers to ensure there is at least one operable fire extinguisher with a minimum 2-A rating on each floor of all community homes, including the basement and attic as required. Documentation of all checks shall be kept and reviewed by the director of operations at least quarterly. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.141(c)(7) | The physical examination, completed 8/3/16 for Individual #2 did not include a gynecological examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The participant attended an appt with her PCP on 11/1/16, and she is not required to have the exam. Staff was re-trained on annual appointment requirements 10/31/16. And, trained on what the doctor should document on the annual physical form if the participant doesn¿t medically need the exam.[Immediately, the CEO shall train Residential Coordinator and the Clinical Program Manager of the requirements of individual physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the aforementioned reviews of physical examinations shall be completed and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.141(c)(8) | The physical examination, completed 8/3/16 for Individual #2 did not include a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The participant attended an appt with her PCP on 11/1/16. She was referred to have a mammogram on 1/4/2017. An annual appt checklist is created and tracked on calendar by the Residential Coord. and Clinical Program Manager. Program Manager. Staff was re-trained on annual appointment requirements 10/31/16. Staff was trained on what the doctor should document on the annual physical form if the participant doesn¿t medically need the exam.[Immediately, the CEO shall train Residential Coordinator and the Clinical Program Manager of the requirements of individual physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the aforementioned reviews of physical examinations shall be completed and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.142(a) | Individual #2 did not have an annual dental examination. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The participant attended an appt with her PCP on 11/2/16, her gums were examined. Prior to admission, each individual will have his/her regulatory medical appts reviewed by the Residential Coord. and followed up with the Clinical Program Manager to avoid overlooked regulatory exams. An annual appt checklist is created and tracked by Residential Coord., Clinical Program Manager to avoid missing all necessary annual appointments.[At least quarterly for 1 year, the CEO shall review individuals dental examination documentation and tracking system to ensure all individuals have dental examinations, timely. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.164(a) | Medications were initialed as administered to Individual #2 from 9/10/16 through 9/29/16 on Individual #2's medication log; although, the corresponding name was not included on the medication administration record. | 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. | A medication administration signature form has been created and placed in the medication binder (where the MAR is located) at each site. The initials and signatures of each staff who is certified with the agency to administer medication will initial and sign the form. This form will be updated by the Medication Administration Trainer on a regular basis. The Clinical Program Manager will visit all sites on a weekly basis using the weekly site visit form to assure that all staff who administered medication to individuals has signed the medication administration record.[Immediately and continuing at least weekly, program manager shall review all individuals' medications, MARs, and physicians orders to ensure all individuals are being administered medications as prescribed and documented as required. The program manager shall retrain staff qualified to administer medications as needed to ensure medications are administer and documented as required. Documentation of all trainings and reviews shall be kept.(AS 1/10/17)] |
12/10/2016
| Implemented |
6400.181(e)(9) | Individual #1's assessment completed 7/16/16 did not include documentation of the individual's disability, including functional medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The disability and functional medical limitations has been added to the assessment. The Residential Coord. (new position since inspection) and Clinical Program Manager will review for accuracy once assessment is completed.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.181(e)(10) | Individual #2's assessment completed 7/26/16 did not include lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. Re-training was done on 10/21/16. The Clinical Program Manager is responsible for completing the assessment and the Residential Coord is responsible for assuring documents are in the chart and complete for avoid future incidents.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.181(e)(13)(vii) | Individual #1's assessment completed 7/16/16 and Individual #2's assessment completed 7/26/16 did not include current levels in the area of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The Residential Coord. and Clinical Program Manager will review final assessment for accuracy. [Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.181(e)(14) | Individual #1's assessment completed 7/16/16 and Individual #2's assessment completed 7/26/16 did not include 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 assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The Clinical Program Manager is responsible for completing the assessment and the Residential Coord will assure that all forms are in the chart and completed accurately.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |
6400.181(f) | The program specialist did not provide Individual #1's assessment dated 11/12/15 to the plan team members including the supports coordinator. | (f) The program specialist shall provide the assessment to the SC, 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).
| A signature form has been created on 10/21 and sent to the team. The Residential Coord. Is responsible for all team members getting a copy and Clinical Program Manager will review for accuracy.
[Immediately, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and document the training. At least quarterly for 1 year the CEO or designated management shall review the documentation showing that the program specialist provided all individuals' assessments to the all the plan team members as required. Documentation of reviews shall be kept. (AS 1/10/16)] |
12/10/2016
| Implemented |
6400.186(d) | The program specialist did not provide Individual #1's ISP review documentation dated 9/21/16 to the plan team members including the supports coordinator. | 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. | A signature form has been created and signed by the team. The form will be filed with the reviews and reviewed by Residential Coord. and Clinical Program. [Immediately, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and document the training. At least quarterly for 1 year the CEO or designated management shall review the documentation showing that the program specialist provided all individuals' ISP reviews to the all the plan team members as required. Documentation of reviews shall be kept. (AS 1/10/16)] |
12/10/2016
| Implemented |
6400.213(1)(i) | Individual #2's record did not include the religious affiliation. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | The Residential Coordinator was hired and trained on the admissions checklist and made the corrections 10/21/16. Upon admissions, each individual will have his/her religious affiliation identified on the admission application completed by the Residential Coord. (new positions since inspection) and reviewed by the Clinical Program Manager prior to actual admission.[Immediately, upon admission and at least quarterly, the program manager and residential coordinator shall review all individuals' records to ensure all required information is present as per 6400.213(1)-(14). Documentation of reviews shall be kept. (AS 1/10/17)] |
12/10/2016
| Implemented |