| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | No self-assessment was completed by the agency. | 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.
| The state assessment form is being used to guide us in our documentation. A site assessment form has been completed and the relevant corrections have been made and implemented. The Program's Specialist will ensure that this assessment is done within the specified time frame and copy be placed on file to avoid a repeat of this violation. |
07/12/2016
| Implemented |
| 6400.46(a) | The agency did not provide orientation for the staff persons employed in the home. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Trainings were provided but not documented. Staff members watched the DVDs of Wild Flower, the Other Sister, Osha Fire Safety,read the policies and procedures of the Agency, ISPS of the individuals admitted, HIPPA, overview of certain modules of the medication administration, etc. The plan of correction that was put in place to prevent a future violation is: All staff members who were previously hired and not signed off on initial trainings received were retrained and allowed to sign off on the trainings received. A detailed training schedule was developed that requires employees to sign off on trainings received. |
07/07/2016
| Implemented |
| 6400.46(e) | There is no documentation of the Program Specialist and the direct service workers having received training in the areas of intellectual disabilities, the principles of normalization, the rights and program planning and implementation. The agency designee stated that there were trainings but the agency did not keep any record of the training. | 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. | Initial trainings were done but was not documented. The CEO had conducted retraining of the Program Specialist and direct workers and have them signed off to confirm that they have received the required training specified by the Department of Human Services. The CEO has put in place the following plan of correction to prevent a repeat of this violation:
A copy of the training policy was reissued to the Program Specialist to remind him of what is required.
The Program Specialist will conduct the initial trainings of new employees.
A checklist of all the relevant initial trainings needed along with signature slots for respective employees to sign off on. |
07/08/2016
| Implemented |
| 6400.68(c) | The home is not connected to a public water system. The home's water was not tested for coliform at least every 3 months. The water in the home was tested on 5/20/2015 and on 5/23/2016 only throughout the past 12 months. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The plan of correction that is put in place to prevent an oversight of this nature is: The Program's Specialist will assign the administrative assistant the task of collecting the container from a certified environmental laboratory, following the laboratory step by step process of how to collect and travel with test sample every three months. Should the test date falls on a day when the laboratory would be closed, the Administrative Assistant will ensure that the water sample is taken and submitted for testing a day or two earlier. |
08/23/2016
| Implemented |
| 6400.112(a) | Unannounced fire drills were not conducted at least once a month. During the month of May 2016, a fire drill was not conducted by the agency. | An unannounced fire drill shall be held at least once a month. | An unannounced fire drill was consistently being done each month since our operation started. However, the fire drill for May 2016, was misplaced among the unpaid invoices and could not be located at the time of licensing. We have since found it and filed it accordingly. The plan of correction that is put in place to prevent a reoccurrence of this kind is: The Program Specialist will check at the end of each month that the fire drill is done and filed away in the right file. |
06/24/2016
| Implemented |
| 6400.113(a) | Individuals 1 and 2 did not receive initial fire safety training. Individual 1 was admitted on 11/2/2015 with fire safety training being received on 3/23/2016 (3 + months late). Individual 2 was admitted on 10/8/2015 and received fire safety training on 3/23/2016 (4 + months late). | 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. | Both Individual 1 and individual 2 watched the Osha fire safety video upon their admittance to the Agency and was made aware of the evacuation procedures, the exits that can be used, the designated meeting place, responsibilities during the fire, the importance of having a fire extinguisher and the locations of the fire extinguishers. They were also made aware of the smoke detectors/ fire alarms and why they should be functional at all times. Also, an initial fire drill was done after watching the video to sensitize the individuals what to do in the event of a fire. This initial training was not documented and signed off by the individuals. The CEO and Program¿s Specialist have put in place the following plan of correction: Upon admittance of individuals/recipients an administrative staff will ensure that after the individual(s) watched the fire safety video and is made aware of all relevant information relating to fire safety that the individual sign off to say that training was administered. The Program Specialist will be more thorough and focused making sure that a repeat of this violation does not happen again. |
03/23/2016
| Implemented |
| 6400.141(c)(3) | Individual 1's physical dated 6/26/2015 does not have a record of his immunizations. | 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. | Individual one was living at home prior to his placement. His Support¿s Coordinator supplied us with a copy of the physical they had on file. Our Agency tried to schedule an appointment with several doctors to get an updated physical that would reflect the requirements of the Department of Human Services; but many of the doctors were not accepting new patients and some did not accept individual 1 medical coverage. In addition, individual 1 medical coverage would not pay for another physical before June of 2016. The CEO and the Program¿s Specialist have put in place the following plan: Our Agency will not accept any placement of recipient without a detailed physical and a copy of the required immunization details. This requested information will be made known to the Support¿s Coordinator or any family member seeking placement for an individual in our Agency. |
06/30/2016
| Implemented |
| 6400.141(c)(6) | Individual 1 was admitted on 11/2/2015. Individual 1's record does not contain a TB test. | 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. | The information provided on the physical form from the County¿s Office is limited. Our Agency had contacted the recipient of service mother to try and get a copy of individual 1 TB test result but failed. We were unable to have it done before individual 1 next physical date in June 2016. The CEO and Program Specialist have put in place the following plan: Our Agency will not accept any placement of recipient without the results of their TB test. This requested information will be made known to the Support¿s Coordinator or any family member seeking placement for an individual. Failure to present this required information will result in rejection of the individual seeking placement. |
07/05/2016
| Implemented |
| 6400.151(a) | Direct service workers 1 and 2 do not have initial physicals on file with the agency. Direct service worker 1 was hired on 10/2/2015 with a physical on file dated 5/27/16. Direct service worker 2 was hired on 10/2/2015 with a physical on file dated 5/5/2016. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Direct service workers 1 and 2 had requested a copy of their physical from their respective employers. The employers were reluctant to provide a copy of the physicals, claiming that they paid for them and that the physicals are their property. The direct workers in question had no direct contact with any recipient of service while our Agency was awaiting their physicals. To date they have not worked with any of the recipients. The CEO and Program Specialist have revisited the hiring process and agreed that any prospective employee will not start any form of training without all the required documentation. In addition, any person seeking employment and do not present all the required documentations within a specified time frame; information will be placed in a file 13. Should that individual reapply all the necessary paperwork will have to be redo depending on the lapse of time. |
06/28/2016
| Implemented |
| 6400.167(b) | Individual 2 is not being administered one of his prescriptions are prescribed by his physician. Individual 2 was prescribed 600 mg Tablet of Ibuprofen to be taken 1 tablet by mouth 3 times daily. However, the medication log for individual 2 states that the medication is a PRN and has not been administered from June 1 through June 21, 2016. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual 2 was prescribed the medication in question, but the pharmacist advised that the medication in question (Ibuprofen) should not be taken with a particular medication(Meloxicam) that the consumer was taking. The Program Specialist called the Health Care Professional and explained the situation and asked that a script be faxed over to our Agency to make the necessary corrections to the medication logs. We have made several calls to the PCP's office but got no response. With the advice from the pharmacist and an earlier script in January 2016 from the doctor to discontinued Ibuprofen, we did not administered the Ibuprofen for safety of the individual. The following plans were put in place to prevent a reoccurrence:
The retained Medication trainer is a licensed LPN, so we will have her call the PCP's office and take verbal instructions to which she can make changes to the medication logs.
If we are unable to get a prompt response from the individual's PCP to address concerned medication issues, the attending staff will take the individual to an Urgent Care Facility to try and have the issue resolved and later scheduled an appointment with his PCP. This individual no longer resides with our Agency since July 7, 2016. |
07/28/2016
| Implemented |
| 6400.168(a) | The agency had no verification of any staff member receiving medication administration training. Individuals are administered medications on a daily basis. According to the agency designee, all staff members were trained at other 6400 agencies that they work at but they do not have the record of such training at Alritch. | In a home serving eight or fewer individuals, 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. | Staff members were trained by another operating agency in the Human Services field, who had provided the staff members with a copy of their certification record; and promised to provide the actual medication training documentations at a convenient time to their agency. We did not receive these documentations until after June 21, 2016. Since then, we have retained the service of a trained DHS medication administration trainer to teach, train and recertify staff members as required by the DHS. Also, we are trying to send an administrative staff to do the training of the trainers medication course to ensure that we have a backup plan in place should our retained trainer not available. |
07/05/2016
| Implemented |
| 6400.181(a) | Records for Individuals 1 and 2 do not contain an assessment. Individual 1 was admitted on 11/2/2015. Individual 2 was admitted on 10/8/2015. The agency designee stated that assessments were not completed for either individual. | 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. | When it was brought to our attention on June 21, 2016 that individual 1 and 2 files did not contain an assessment; we created assessments for the individuals on June 23 and 24 respectively. In future, the Program Specialist and the Administrative Assistant will ensure that all assessments will be done in a timely manner according to the DHS regulations. They have agreed not to let another repeat of this violation happens again. |
06/23/2016
| Implemented |
| 6400.186(b) | Individual 1's ISP review dated 6/16/16 was not signed by the Program Specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | On June 16, 2016, when we had the Quarterly Review for one of the individuals, the Program Specialist had an appointment that he was unable to reschedule, and as a result ask another administrative staff with equal qualifications and of equal competence to do the meeting on his behalf.
In the future if our Program Specialist is unable to be in attendance at these meetings we will try to reschedule the meetings, to have the Program Specialist in attendance and try to be incompliance with the allowed timeframe in which the meeting is to be conducted. |
06/22/2016
| Implemented |
| 6400.186(c)(2) | All areas of the ISP are not being reviewed during the 3 month reviews for both Individuals 1 and 2. The ISP reviews do not include safety skills, communication, or supervision needs. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The provider completed quarterly reviews for both individuals which omitted some required details. These details have since been added and attached to the individuals' files . The current form has been updated to include safety skills, level of supervision. and communication needs as was requested to prevent a repeat of this violation. The CEO has agreed to supervise the Program Specialist more closely and to check files periodically (every month). |
06/27/2016
| Implemented |
| 6400.186(e) | The option to decline the ISP review documentation is not being given to the team members of individuals 1 or 2. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The Program Specialist added a section for members of the ISP team to decline the review documentation for the ISP. For future ISP review meetings, the Program Specialist, will make sure that the option to decline the ISP documentation is done. |
06/27/2016
| Implemented |
| 6400.213(1)(i) | Both individuals 1 and 2 are missing personal information from their records. Identifying marks are not noted in the records of Individual 1 and 2. Both individual 1 and 2 do not have dates on their photos. | 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. | Photographs were taken of both individuals upon their respective arrival dates. Their were no noticeable identifying marks which we inadvertently omitted to state on their information sheets. Since, June 21, 2016, when it was brought to our attention by the licensor, we have updated the information sheet to reflect the changes.
The administrative staff members were made aware of this violation and have all agreed to be more meticulous in the performance of their duties to avoid reoccurrence of this nature. The Program Specialist will ensure that he/she checks all information sheets against the 6400 regulations to make sure that our Agency is in compliance. |
06/22/2016
| Implemented |