| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The water temperature 137.8 degrees F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature did exceed 120 degrees at the time of licensing. Annually, a contracted plumber/ HVAC technician assesses the heating/ HVAC and water temperature in each residence. Their findings are indicated per contract on each invoice. Over the last year the contractor tested the water temperature twice in this residence, indicating that the temperature did not exceed 120 degrees. Evidently the contractors readings are skewed from that of the Licensing Representative. To prevent a future occurrence the water temperature will be checked minimally every quarter during our health and safety audit. These audits are carefully documented to ensure the health and safety of all those we serve. Additionally, digital temperature gauges were purchased for use by Residential Supervisors. They will complete random and periodic checks of the water in each of their assigned residences. |
08/14/2019
| Implemented |
| 6400.73(a) | There were more than 2 steps leading up through the Bilco doors of this residence. There was no handrail at this exit. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | There are more than two steps leading through the bilco doors to the outside of the residence and a railing is not present. A railing was ordered and installed. The maintenance manager, purchasing agent, Director of Operation and Director of Residential Services were all trained on how to properly count steps with a demonstration from the Executive Director. The Maintenance Manger and Director of Operation surveyed all other properties to ensure compliance. Prior to procuring any future properties the purchasing agent will ensure the proper step to railing ratio. |
08/14/2019
| Implemented |
| 6400.113(a) | Individual #2 was admitted on 3/15/2019. She didn't receive fire safety training until 3/24/2019. | An individual, including an individual 17 years of age or younger, 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 home. | While initial fire safety training and assessment was completed within 30 days of admission, it was not completed on the day of admission, therefore; not meeting the regulatory standard. This procedure was updated to include the new time frame of completion within the first 24 hours of admission. This procedure was updated and implemented effective July 22, 2019. All Program Specialists, Directors, Nurses and Health Risk Screeners received training on this procedural update July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(1) | This section was not on Individual #2's Assessment dated 3/15/2019. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | We have created an initial assessment that includes an individual's functional strengths, needs and preferences. Updates were made to the current quarterly and annual assessment form. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialists, Directors, Nurses and Health Risk Screeners have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(2) | This section was not on Individual #2's Assessment dated 3/15/2019. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Our functional assessment, which we were using as an initial assessment, captured this information. This however did not meet the standard. We have created an initial assessment that includes the individual's likes, dislikes and interests. Updates were made to the current quarterly and annual assessment form. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialists, Directors, Nurses and Health Risk Screeners have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(12) | This section was not on Individual #2's Assessment dated 3/15/2019. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | We have created an initial assessment that includes recommendations for specific areas of training, programming and services. Updates were made to the current quarterly and annual assessment form. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialists, Directors, Nurses and Health Risk Screeners have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(13)(vii) | This section was not on Individual #2's Assessment dated 3/15/2019. | 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.
| Our functional assessment, which we were using as an initial assessment, captured this information. This however did not meet the standard. We have created an initial assessment that captures an individuals ability to manage their finances independently. Updates were made to the current quarterly and annual assessment form that will allow the Program Specialist to indicate on going progress. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialist and Directors have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(13)(viii) | This section was not on Individual #2's Assessment dated 3/15/2019. | 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. | Our functional assessment, which we were using as an initial assessment, captured this information. This however did not meet the standard. We have created an initial assessment that captures an individuals ability to manage personal property and money. Updates were made to the current quarterly and annual assessment form that will allow the Program Specialist to indicate on going progress. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialist and Directors have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(13)(ix) | This section was not on Individual #2's Assessment dated 3/15/2019. | 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. | Our quarterly assessment captured this information. However, it was not on our functional assessment, which we were using as an initial assessment. We have created an initial assessment that captures an individuals current level of community integration. Updates were made to the current quarterly and annual assessment form that will allow the Program Specialist to indicate on going progress. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialist and Directors have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.181(e)(14) | The ability to regulate water temperature was not assessed on Individual #2's Assessment dated 3/15/2019. | 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. | We have created an initial assessment that includes an individuals water safety, ability to swim and regulate water temperature. Updates were made to the current quarterly and annual assessment form. Each individuals quarterly assessment will document progress and the annual assessment will indicate progress over the previous 365 days. All Program Specialist, Nurses and Health Risk Screeners have received training on the initial assessment, the updated quarterly assessment and the updated annual assessment. It is the responsibility of the Program Specialist to ensure the initial assessment, quarterly assessment and annual assessment are completed and accurate. The initial assessment form was created on July 15, 2019. Additionally, quarterly and annual assessments were updated to reflect the new information on July 15, 2019. Personnel received training on July 19/20 respectively. |
08/14/2019
| Implemented |
| 6400.165(g) | The Psych Med Review form does not include the reason for prescribing the medication, the need to continue and the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The medical appointment form that is currently used was updated to include a separate section that would allow a licensed physician to indicate a 3 month review and reason for prescribing a medication that is treating a psychiatric illness. This change was implemented on July 15, 2019. All personnel responsible for medical appointments received training on this updated form on July 19/ 20 respectively. It will be responsibility of the Quality Manager to ensure ongoing compliance and training when necessary. |
08/14/2019
| Implemented |