| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed 3 to 6 months prior to license expiration date.((repeat violation 3/23/17)) | 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.
| Quality of life Human Services Director and office manager has made an annual checklist with dates of our required inspections, renewals and certificate of compliance needed for our agency to be in compliant with our state regulations . The checklist will be checked monthly (first week) and update with dates that the certificate of compliance and other required inspections , renewals was completed |
04/11/2018
| Implemented |
| 6400.31(b) | Individual #2 did not have acknowledgment of receipt of information on rights in his record. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | rights record was given and explained with receipt of signature. Residents charts will be checked by The Director and Staff team leader will Check residents charts to make sure all required documentation is in there charts and complete all resident charts will be updated immediately when required . Director and team lead will check there residents charts every 2 weeks to make sure all required documentation is complete.
Individual #1 and #2 race has been added to there charts |
04/11/2018
| Implemented |
| 6400.62(a) | Unlocked poisons (Works Brand Basic' spray bathroom cleaner and Lysol disinfectant spray -- contact poison control if ingested') were discovered under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The staff will do a daily walk through to make sure everything is present and in working order and safe (All poisonous materials will be kept in locked area away from residents )to be in-compliant of state regulations Staff will report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out.
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.62(c) | An unlabeled bottle of liquid resembling liquid soap was found under the sink in the hall bathroom. | Poisonous materials shall be stored in their original, labeled containers. | The staff will do a daily walk through to make sure everything is present and in working order and safe (All poisonous materials will be kept in locked area away from residents )to be in-compliant of state regulations Staff will report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out.
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.66 | The light in the basement stairwell was not operable. Also, the light fixture in the basement mechanical room did not have a lightbulb | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out
light has been added to stairway
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.67(a) | There were approximately 14 holes of varying size in the walls in Individual #1's bedroom, likely resultant from punching or kicking the walls. Also, the wall on the outside of the tub/shower enclosure had a rough, unfinished edge in the hallway bathroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out
walls are in process of being fixed
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/13/2018
| Implemented |
| 6400.67(b) | There was a window air conditioning unit with sharp, metal, rusting edges sitting on the floor in Individual #1's bedroom. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out . Air conditioner was moved to safe area away from resident
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.73(a) | The handrail on the outside stairs off the kitchen, leading to the backyard, ends before the last three steps on the bottom. Also, the handrail on the stairs to the basement ends before the last two steps and bottom landing. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | the handrails have been fixed
The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.80(a) | The outside steps leading to the front door were icy. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Director will make sure the staff is taking care of all walkways to make sure there free from ice , snow and other obstructions. Director will make sure staff has supplies needed to do this task
((Quality Life Human Services will develop a written procedure for snow and ice removal. Staff will be trained in this procedure. Documentation of this training shall be kept. -CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.81(i) | The bedroom window located near Individual #1's bed did not have curtains, blinds or a shade. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | curtains were hung in individual # 1 bedroom The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.81(k)(6) | There was no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | The staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out mirror was hung in individual #1 bedroom
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.82(f) | There was no wall mirror in the hall bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | there was a mirror installed in the bathroom the staff will do a daily walk through to make sure everything is present and in working order to be in compliant of state regulations report to director of anything needed or not working properly
director will also do monthly walk through to make sure that it is being carried out
((All staff will be trained on the physical site requirements of Chapter 6400 regulations. Documentation of this training shall be kept. Documentation of the date and time daily checks occurred and any problem areas encountered will be kept. Documentation of monthly checks to include the date the check occurred and any problem areas encountered will be kept. - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.112(a) | There was no monthly fire drill for February 2018. | An unannounced fire drill shall be held at least once a month. | There will be a calendar in main office with date of each month fire drill will be conducted director or office manager will make sure unannounced drill is carried out and documented
((All Quality Life Human Services' staff will receive training in the fire drill requirements of Chapter 6400 -CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.112(h) | There was no identified meeting place on any of the fire drill logs. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | the director will make sure-there will be a designated meeting place documented in our fire log .
((Quality Life Human Services will review all evacuation procedures to ensure compliance with Chapter 6400 regulations. Updates to the evacuation procedures will completed as necessary. All staff and individuals will be retrained in evacuation procedures. Documentation of this training shall be kept. -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.141(c)(3) | Individual #2 has not received his TDaP since 09/03/96 when he was one year of age. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Director and office manager will check resident physical - immunizations to make sure immunizations are up to date and schedule appointment with PCP if updated immunizations are required. individual #2 PCP will check into immunization history and will schedule appointment to update his immunizations
((All Quality Life Human Services staff will be trained in the requirements of the physical. Documentation of this training shall be kept -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.141(c)(6) | Individual #2 was admitted on 03-25-16 and did not have a TB test until 06-13-16. | 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. | Chart will be kept of residents due date of physical - TB test Director or office manager will have copy when due date will set up appointment at least 1 month prior to due date
Director and office manage will make sure TB test is completed every 2 years
((All Quality Life Human Services staff will be trained in the requirements of the physical. Documentation of this training shall be kept -CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.141(c)(11) | The section addressing health maintenance needs was left blank on Individual #1's physical form. The section pertaining to the assessment of health maintenance needs was also left blank on Individual #2's physical. | 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. | When receiving residents physical forms from the doctor the director and office manager will check the documentation to make sure it is completed entirely before filing
if incomplete form will be sent back to doctor for him to complete
((All Quality Life Human Services staff will be trained in the requirements of the physical. Documentation of this training shall be kept. The physician for Individual #1 and Individual #2 will be contacted and the missing information will be added to the physical. -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.141(c)(14) | The section regarding information pertinent to diagnosis and treatment in case of emergency was left blank on Individual #1's and Individual #2's physical forms. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | When receiving residents physical forms from the doctor the director and office manager will check the documentation to make sure it is completed entirely before filing
if incomplete form will be sent back to doctor for him to complete
((All Quality Life Human Services staff will be trained in the requirements of the physical. Documentation of this training shall be kept. The physician for Individual #1 and Individual #2 will be contacted and the missing information will be added to the physical. -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.142(e) | On Individual #1's dental form from 05/24/17 it states patient to be seen in OR for exam, cleaning, etcetera. Patient had several cavities and poor oral hygiene.' Individual #1 was referred for the oral surgery, but there is no documentation in his file that it was ever completed. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Staff will notify Director of any follow-up appointments. with specialists or referrals Director will ensure these appointments are set up and followed through and proper documentation to maintained in resident charts
We will be setting up Individual #1 appointment and documentation will be in chart of appointment
((Quality Life Human Services will develop a written procedure regarding scheduling medical appointments to include follow-up appointments. All staff will be trained in this procedure. Documentation of the training shall be kept. -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.161(e) | The medication Fluticasone nasal spray which was discontinued in January 2018 was found in Individual #1's medication box.((repeat 3/23/17)) | Discontinued prescription medications shall be disposed of in a safe manner. | med box will be matched up with MAR's any medication that is discontinued or not on MAR's will be returned to the pharmacy or disposed of properly MARs and med box will be checked weekly by the staff Team Lead and followed up with monthly check by director or office manager. Refresher training will be given to staff
((Quality Life Human Services will develop written procedures in regards to monthly medication checks. Monthly checks will include all areas specified in regulations 6400.161 through 6400.169. Documentation of the monthly checks will include staff name and title completing the check, date of the check, any problems found during the check and their resolutions. This documentation shall be kept. -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.181(a) | The only assessment in Individual #1's file was from the ARC ATF. No residential assessment was ever completed.((repeat 3/23/17)) | 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. | Residents will have the required assessment form within 60 days of admission or less than 1 year prior / assessments will be done annually date assessment is due will be marked on calendar with a reminder 1 month before list of residents assessment due dates will be available at office Director or office manager will notify 1 month prior of due date., and follow up to make sure assessment is completed
((Individual #1 will have an assessment completed by 6/1/18. Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.181(e)(1) | The section pertaining to strengths, needs, and preferences was left blank on Individual #2's assessment. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | upon completion of assessment Director and office manager will check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(2) | The section pertaining to dislikes was left blank on Individual #2's assessment. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Upon completion of assessment Director and office manager will check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(3)(i) | The section pertaining to acquisition of functional skills was left blank on Individual #2's assessment. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | upon completion of assessment Director and office manager will double check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(3)(iv) | The section pertaining to personal needs with or without assistance was not addressed on Individual #2's assessment. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Upon completion of assessment Director and office manager will double check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(4) | The section pertaining to need for supervision was not addressed on Individual #2's assessment. | The assessment must include the following information: The individual's need for supervision.
| upon completion of assessment Director and office manager will check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(9) | The section pertaining to documentation of the individual's disability was not anywhere on Individual #2's assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | upon completion of assessment Director and office manager will double check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Submitted |
| 6400.181(e)(10) | The section pertaining to lifetime medical history was not anywhere on Individual #2's assessment. | The assessment must include the following information: A lifetime medical history. | upon completion of assessment Director and office manager will check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(12) | Recommendations were not anywhere on Individual #2's assessment. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | upon completion of assessment Director and office manager will check documentation to ensure it is filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of health. | 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.
| upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(ii) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of personal adjustment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(v) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed 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.
| upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
All assessments will be completed in the required amount of time per state regulations
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(viii) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
All assessments will be completed in the required amount of time per state regulations
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(e)(13)(ix) | Individual #2's progress and growth over the last 365 calendar days and current level was not addressed in the area of community integration. | 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. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
All assessments will be completed in the required amount of time per state regulations |
04/11/2018
| Implemented |
| 6400.181(e)(14) | The section pertaining to knowledge of water safety/ability to swim was not anywhere on Individual #2's assessment. | 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. | upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #2 assessment has been completed
All assessments will be completed in the required amount of time per state regulations
((Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Implemented |
| 6400.181(f) | Since no residential assessment was ever completed for Individual #1, none was sent to the team before the most recent ISP meeting.
The ISP meeting for Individual #2 was on 05/15/17 and there is no documentation that the 03/27/17 assessment was sent at least 30 days prior to the ISP meeting. | (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).
| upon completion of assessment Director and office manager will check documentation to ensure all areas are filled out entirely before it is filed. Individual #1 assessment has been completed
All assessments will be completed in the required amount of time per state regulations and sent to plan team member at least 30 days prior to ISP meeting
((The assessment for Individual #1 will be sent to the team. Program Specialist will be trained in the requirements of the assessment. Documentation of this training shall be kept - CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.184(c) | There was not an ISP meeting signature sheet in Individual #1's file. | A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet. | Director and Plan team member will thoroughly check to make sure documentation is complete before a document is filed in there charts. Team lead will check resident charts on a monthly basis to make sure all charts are complete. |
04/11/2018
| Implemented |
| 6400.186(a) | No three month reviews were completed for Individual #1 or Individual #2. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The program specialist will do an ISP of services every 3 months as state regulations require calendar checklist will be kept of date review is due and date of new review . The office manager will also have list of when review is due she'll contact program specialist to verify review is going to be done at the required time
((Program Specialist will receive training in the requirements of this regulations -CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.186(c)(1) | No monthly reviews were completed for Individual #1 or Individual #2. | 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 residential home licensed under this chapter. | checklist will be kept of date ISP review is due and date of new review . The office manager will also have list of when review is due she'll Director to verify review is being done at the required time (monthly) and documentation is on file
((Quality Life Human Services will train the Program Specialist and all staff on the requirements to document monthly participation and progress towards outcomes. Quality Life Human Services will develop a procedure for the proper documentation of participation and progress towards outcomes. Training and monthly documentation shall be kept - CH 4/20/18)) |
04/11/2018
| Not Implemented |
| 6400.213(1)(i) | There was nothing identifying Individual #1's or Individual #2's race in their files. | 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 Director and team leader will Check residents charts to make sure all required documentation is filled in and all resident charts will be updated immediately when required . Director and team lead will check there residents charts every 2 weeks to make sure all required documentation is complete.
Individual #1 and #2 race has been added to there charts |
04/11/2018
| Implemented |