| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment for the home. The home's certificate of compliance has expiration date 1/9/18. | 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.
| Persons Responsible-Executive Director & Assistant Director Action-NF, will ensure 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. Protocol-Executive Team created an annual checklist that covers all important task according 6400 regulations that will also cover the agency¿s self-assessments to ensure all areas are not missed. All system should be in place be 3/9. Compliance Officer will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [Immediately, the agency shall complete a self-assessment for all community homes. Prior to 3 months of expiration of Certificate of Compliance, the CEO or designee shall audit all self-assessments of each home to ensure completion, timely. Documentation of aforementioned quarterly inspections by the compliance officer shall be kept. (AS 3/23/18)] |
03/09/2018
| Not Implemented |
| 6400.31(b) | Individual #1, date of admission 5/20/17, did not have a signed statement acknowledging receipt of the information on rights. | 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. | NF created admission checklist, 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. Progran Spiealist on the checklist to aesure the statement was signed.[Immediately, the program specialist shall inform Individual #1 of the individual right as per 6400.33(a)-(m) and a signed and dated statement acknowledging receipt of the information on rights shall be maintained. Immediately, the program specialist shall review all individuals' records to ensure all individuals have been informed of individual right as required. At least quarterly, designated management staff person shall review individuals' records to ensure all individuals' have been informed of individual rights and signed and dated statement is kept. Documentation of quarterly review shall be kept. (AS 3/23/18)] |
03/09/2018
| Not Implemented |
| 6400.112(a) | The fire drills were conducted on 5/21/17, 6/21/17, 7/21/17, 8/21/17, 9/21/17 and 10/21/17. | An unannounced fire drill shall be held at least once a month. | Persons Responsible-Program Specialist & Program Coordinator Action-Not Forgotten has scheduled unannounced fire drills only the Program Specialist & Program Coordinator is aware of. The PS & PC will document the dates & times of those drills.Protocol-Program Specialist and Program Coordinator are finalizing procedures for all staff to be trained. A document will be created to record all unannounced fire drills. All Staff and individual will be trained. All system should be in place be 3/9. The Program Coordinator will monitor fire drill records to make sure they are up to date. Assistant Director will perform a quarterly inspection of fire drills recorded documentation and will report issues and concerns to a quality management team.Next inspection will be 3/9/2018. [Fire drills were held in January and February 2018. Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall train all staff person responsible for conducting and participating and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I) and their responsibilities to ensure fire drills are held and documented as required. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.112(c) | The fire drills records for the fire drills held on 5/21/17, 6/21/17, 7/21/17, 8/21/17, 9/21/17, 10/21/17, 11/22/17, and 12/19/17 did not include exit route used, problems encountered or if the smoke detector was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Persons Responsible-Program Specialist & Program Coordinator Action-A written fire drill record is being created
Protocol-Program Specialist and Program Coordinator are finalizing procedures for staff to be trained. A document will be created is kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. All Staff and individual will be trained. All system should be in place be 3/9. The Program Coordinator will monitor fire drill records to make sure they are up to date. Assistant Director will perform a quarterly inspection of fire drills recorded documentation and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. |
03/09/2018
| Implemented |
| 6400.112(d) | The fire drills conducted on the following dates had the following evacuation times: 5/21/17, 4 minutes; 6/21/17, 4 minutes 20 seconds; 7/21/17, 4 minutes 28 seconds; 8/21/17, 3 minutes 30 seconds; 9/21/17, 3 minutes 24 seconds; 10/21/17, 4 minutes 46 seconds; 11/22/17, 3 minutes; 12/19/17, 3minutes 10 seconds. The home does not have an extend evacuation time in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Persons Responsible-Program Specialist & Program Coordinator Action-Program Specialist & Program Coordinator will notify a fire safety expert outside the agency to assist the protocol of Individuals being able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time. Protocol-Program Specialist and Program Coordinator are finalizing procedures for staff to be trained. A document will be created is kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire expert will sign off on it annually. All Staff and individual will be trained. All system should be in place be 3/9. The Program Coordinator will monitor fire drill records to make sure they are up to date.
Assistant Director will perform a quarterly inspection of fire drills recorded documentation and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [Individual #1 was relocated to another home within the agency. Fire drills were held in January and February 2018. Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall train all staff person responsible for conducting and participating and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I) and their responsibilities to ensure fire drills are held and documented as required. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.112(e) | There has not been a fire drill held during sleeping hours from 5/21/17 to 12/19/17. | A fire drill shall be held during sleeping hours at least every 6 months. | Persons Responsible-Program Specialist & Program Coordinator Action-Not Forgotten has scheduled a fire drill shall be held during sleeping hours on 5/18/2018 every 6 months. The PS & PC will document the dates & times of those drills.Protocol-Program Specialist and Program Coordinator are finalizing procedures for all staff to be trained. The fire drills will be documented. All Staff and individual will be trained. All system should be in place be 3/9. The Program Coordinator will monitor fire drill records to make sure they are up to date.
Assistant Director will perform a quarterly inspection of fire drills recorded documentation and will report issues and concerns to a quality management team.Next inspection will be 3/9/2018. [A fire drill was held during sleeping hours in February 2018.Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall train all staff person responsible for conducting and participating and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I) and their responsibilities to ensure fire drills are held and documented as required. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.112(h) | The fire drills records for the fire drills on 5/21/17, 6/21/17, 7/21/17, 8/21/17, 9/21/17, 10/21/17, 11/22/17, and 12/19/17 did not include if the individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Persons Responsible-Program Specialist & Program Coordinator Action-Not Forgotten has designated meeting place outside the building or within the fire safe area during each fire drill. NF will document the spot for staff and individuals to see.Protocol-Program Specialist and Program Coordinator are finalizing procedures for all staff to be trained. A document will be created to record all fire drills. All Staff and individual will be trained. All system should be in place be 3/9. The Program Coordinator will monitor fire drill records to make sure they are up to date.
Assistant Director will perform a quarterly inspection of fire drills recorded documentation and will report issues and concerns to a quality management team.Next inspection will be 3/9/2018. [A fire drill was held during sleeping hours in February 2018.Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall train all staff person responsible for conducting and participating and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I) and their responsibilities to ensure fire drills are held and documented as required. Documentation of the trainings shall be kept. At least monthly for 1 year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.113(a) | Individual #1, date of admission 5/20/17, was not instructed in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place upon admission. | 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. | Persons Responsible-Program Specialist & Program Coordinator Action-Program Specialist & Program Coordinator are creating a checklist for new admissions and staffing that instructs them in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place upon admission. Protocol-
Program Specialist and Program Coordinator are finalizing procedure and checklist for new admissions and staffing that instructs them in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place upon admission. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of admission and staff training documentation and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [Immediately, Individual #1 shall be instructed 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. Documentation shall be training shall be kept as required and available for review by the Department upon request. Immediately, upon admission and annually, the CEO or designated management staff person shall audit all individuals' fire safety trainings to ensure timely completion. Documentation of audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 11/7/17 did not include health maintenance. This section was blank. | 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. | Not Forgotten has updated the documentation for the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals in the assessment tool. [Immediately, upon admission and upon completion, the CEO or designated management or nursing staff person shall audit all individual's physical examination to ensure timely competition and all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment completed 8/21/17 did not include documentation of Individual #1's disability. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Not Forgotten has updated the documentation of the individual's disability, including functional and medical limitations to assessment tool.[Individual #1's assessment was signed by the Acting Program specialist. Immediately, the CEO shall educate the Program Specialist of the required information in Individuals' assessments as per 6400.181e(1)-(14). Documentation of the training shall be kept. At least quarterly for 1 year the CEO shall audit the completed assessment to ensure the Program specialist completed all individuals' assessments with required information, timely. Documentation of the audit shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed 8/21/17 did not include A lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Not Forgotten has updated the documentation of the individual's disability, the assessment must include the following information: A lifetime medical history.[Individual #1's assessment was signed by the Acting Program specialist. Immediately, the CEO shall educate the Program Specialist of the required information in Individuals' assessments as per 6400.181e(1)-(14). Documentation of the training shall be kept. At least quarterly for 1 year the CEO shall audit the completed assessment to ensure the Program specialist completed all individuals' assessments with required information, timely. Documentation of the audit shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed 8/21/17 did not recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Not Forgotten has updated the documentation for specific areas of training, programming and services to the assessment tool.[Individual #1's assessment was signed by the Acting Program specialist. Immediately, the CEO shall educate the Program Specialist of the required information in Individuals' assessments as per 6400.181e(1)-(14). Documentation of the training shall be kept. At least quarterly for 1 year the CEO shall audit the completed assessment to ensure the Program specialist completed all individuals' assessments with required information, timely. Documentation of the audit shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.181(e)(14) | Individual #1's assessment completed 8/21/17 did not include Individual #1's 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. | Not Forgotten has updated the documentation for 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 in the assessment tool.[Individual #1's assessment was signed by the Acting Program specialist. Immediately, the CEO shall educate the Program Specialist of the required information in Individuals' assessments as per 6400.181e(1)-(14). Documentation of the training shall be kept. At least quarterly for 1 year the CEO shall audit the completed assessment to ensure the Program specialist completed all individuals' assessments with required information, timely. Documentation of the audit shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.186(a) | The program specialist did not complete ISP reviews for Individual #1, date of admission 5/20/17. | 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. | Not Forgotten program specialist completed 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. [Individual #1 has been relocated to another home within the agency. Individual #1 had an ISP review for review period 11/8/17 to 2/8/18 which was not dated or signed by the program specialist. Immediately, the CEO shall train the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Immediately, the program specialist shall complete a current ISP Review for Individual #1 and provide to the plan team members as required. Immediately, the Program specialist shall develop and implement a tracking system to ensure ISP reviews for all individuals are completed, timely. At least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and all individuals' ISP reviews to ensure the program specialist completes all individuals ISP reviews, timely. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Not Implemented |
| 6400.186(c)(1) | The program specialist did not complete a review of the monthly documentation for Individual #1. | 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. | Not Forgotten, the ISP review now includes 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. [Immediately, the CEO shall train the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Immediately, the program specialist shall ensure a current monthly documentation for Individual is completed and the Program specialist shall review, sign and date as required and include in the ISP reviews. Immediately, the Program specialist shall develop and implement a tracking system to ensure ISP reviews for all individual are completed with a review of the monthly documentation of an individual participation and progress. At least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and all individuals' ISP reviews to ensure the program specialist completes all individuals ISP reviews with a review of monthly documentation of an individual's participation and progress during the prior 3 months. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Not Implemented |
| 6400.186(e) | The program specialist did not notify Individual #1's plan team members of the option to decline the ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Not Forgotten program specialist shall notify the plan team members of the option to decline the ISP review documentation as per implemented in policy and procedure. [Immediately, the CEO shall train the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Immediately, the program specialist shall notify Individual #1's plan team members of the of the option to decline the ISP review documentation. Immediately, the program specialist shall audit all individuals' records to ensure all plan tam members for all individuals have been notified of the option to decline the ISP review documentation and documentation of the correspondence is kept in the individuals' record and available for review upon request by the Department. At least quarterly for 1 year, the CEO shall audit all individuals' records to ensure all plan team members have been notified of the option to decline ISP review documentation and documentation of the correspondence is kept in the individuals' record and available for review upon request by the Department. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Not Implemented |