| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, date of admission 7/1/17, 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. | Persons Responsible-Program Specialist & Program Coordinator
Action-Not Forgotten will ensure documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: ISP review signature sheets will be completed.[NOT ACCEPTABLE, Plan of correction does not address violation. (AS 3/23/18)]
Protocol-Program Specialist and Program Coordinator will create checklist to make sure 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 according to regulations.
All system should be in place be 3/9.
Assistant Director 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 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 |
| 6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Persons Responsible-Program Specialist & Program Coordinator
Action-Not Forgotten has placed telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
Protocol-Program Specialist and Program Coordinator will create checklist to make sure telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line according to regulations are covered.
All system should be in place be 3/9. Assistant Director 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. [Within 30 days of receipt of the plan of correction and upon hire, a designated management staff person train all staff persons of the telephone numbers required by all telephones and to use if needed. Immediately, upon opening new homes and continuing at least quarterly, the CEO or designated management staff person shall completed onsite checks of all community homes to ensure all required telephone numbers are on or by each telephone with an outside line. Documentation of all checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer or tweezers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Persons Responsible-Nurse Coordinator Action-Tweezers were placed in the first aid kit. Protocol-Nurse Coordinator is creating an inventory checklist and will train Residential Staff to follow daily. If an item is missing, the RS will notify NC. The NC will investigate what happen and will the protocol of her findings. The items will be replaced immediately in the first kit to make sure the health and safety of the individual is being met. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of trainings and documentation of inventory checklist to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team. Next inspection will be 3/9/2018. [Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate all staff persons working in community homes of the required items in first aid kits and the agency's replacement and replenishment procedures to ensure all required items are in first aid kits at all times. Documentation of trainings shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.81(i) | Individual #2's and Individual #3's bedrooms did not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Person Responsible-Maintenance Facilitator Action-Curtains were installed to the bedrooms.
Protocol-Maintenance Facilitator will perform a quarterly check o to make sure the bedroom windows shall have drapes, curtains, shades, blinds or shutters. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem. Next inspection will be 3/9/2018. [Immediately, upon opening a licensed home and continuing at least quarterly, the CEO or designated management staff person educated as to the required items in individuals' bedrooms including that bedroom windows shall have drapes, curtains, shades, blinds or shutters shall complete onsite check of all community homes to ensure all individuals bedrooms have all required items. Documentation of onsite checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.81(k)(4) | Individual #3's bedroom did not have a chest of drawers. | In bedrooms, each individual shall have the following: A chest of drawers. | Person Responsible-Maintenance Facilitator Action-Bedroom now has a chest. Protocol-Maintenance Facilitator will perform a quarterly check o to make sure the bedrooms, each individual shall have the following: A chest of drawers. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.
Next inspection will be 3/9/2018. [Immediately, upon opening a licensed home and continuing at least quarterly, the CEO or designated management staff person educated as to the required items in individuals' bedrooms including that bedroom shall have a chest of drawers shall complete onsite check of all community homes to ensure all individuals bedrooms have all required items. Documentation of onsite checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.81(k)(6) | Individual #3's and Individual #1's bedrooms did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | Person Responsible-Maintenance Facilitator
Action-Both bedroom now has a mirrors. Protocol-Maintenance Facilitator will perform a quarterly check o to make sure in bedrooms, each individual shall have the following: A mirror. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018. [Immediately, upon opening a licensed home and continuing at least quarterly, the CEO or designated management staff person educated as to the required items in individuals' bedrooms including that bedrooms shall have a mirror shall complete onsite check of all community homes to ensure all individuals bedrooms have all required items. Documentation of onsite checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.110(a) | The home, which has three floors, did not have a smoke detector on the first and second floors. The smoke detector located on the third floor was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Person Responsible-Maintenance Facilitator Action-Interconnected smoke detectors were installed to three floors.
Protocol- Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable automatic smoke detector on each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [On 3/22/18, smoke detectors were on each floor of the home, interconnected and audible throughout the home. Immediately, upon opening a new and continuing at least monthly, CEO or designated management staff person shall check the smoke detectors in all community homes to ensure there is a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.110(e) | The home, which has three floors, did not have interconnected smoke detectors. | 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. | Person Responsible-Maintenance Facilitator Action-Interconnected smoke detectors was installed on all three floors. Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable automatic smoke detector on each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.
Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s) [On 3/22/18, smoke detectors were on each floor of the home, interconnected and audible throughout the home. Immediately, upon opening a new and continuing at least monthly, CEO or designated management staff person shall check the smoke detectors in all community homes to ensure there is a there is 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. Documentation of checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.111(a) | The home did not have a fire extinguisher on the second and third floors of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Person Responsible-Maintenance Facilitator Action-At least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic was added to each floor. Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing fire extinguisher. MF will follow protocol of immediately replacing, adding fire extinguisher (s). [Immediately, upon opening new homes and at least monthly, the CEO or designated management staff person shall check fire extinguishers to ensure there is at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Documentation of checks shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.113(a) | Individual #1, date of admission 7/1/17, 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 educated in fire safety as required. Documentation of training shall be kept. Immediately, upon admission and annually, the CEO or designated management staff persons shall review all individuals' fire safety training to ensure completion and documentation of the training is kept as required. (AS 3/23/18)] |
03/09/2018
| Not Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 7/1/17, had Tuberculin skin testing by Mantoux method with negative results on 12/13/17. | 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. | Persons Responsible-Nurse Coordinator Action-Nurse will create a medical checklist for new admissions that demonstrate individuals will have physicals examinations that includes Tuberculin skin testing by Mantoux method upon admission and annually. Protocol-Nurse Coordinator create a medical checklist for new admissions that demonstrate individual¿s 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. will have physicals examinations that includes upon admission and annually. New admission will not be able to move in without the physical examination. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of nurse¿s documentation to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018. [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)] |
03/09/2018
| Implemented |
| 6400.142(f) | Individual #1, date of admission 7/1/17, did not have a dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Persons Responsible-Program Specialist & Program Coordinator Action-NF program specialist will provide Individual #1's assessment.Protocol-Program Specialist and Program Coordinator are updating a new functional assessment tool. In following, the Program Coordinator 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). according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [NOT ACCEPTABLE, plan of correction does not address violation. On 3/21/18, Individual #1 had a dental hygiene plan in the record to included an outcome. Immediately, upon admission and at least quarterly, the CEO or designated management staff person shall audit all individuals' records to ensure all individuals have a current written plan for dental hygiene unless interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Documentation of the audits shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.164(b) | On 12/28/17, at 12:20PM, Individual #1's prescription medication Clobetasol .05% solution was not present in home. Individual #1's prescription medication Clobetasol .05% solution: Apply 1ml on the skin twice a day was not initialed as administered on 12/7/17, 12/20/17, 12/21/17, 12/28/17 at 8:00AM and 12/23/17 at 8:00PM. Individual #1's prescription medication Clobetasol .05% ointment: Apply to trunk, arms, and legs twice daily was not initialed as administered on 12/7/17, 12/20/17, 12/21/17, 12/28/17 at 8:00AM. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Persons Responsible-Nurse Coordinator Action-All staff are trained by a certified Med Trainer to ensure the information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication or retrained after repeated errors.Protocol-Nurse will create a medical checklist to check sites when she does weekly rounds of monitoring medication charts. The nurse is make sure the information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.All system should be in place be 3/9.
Compliance Officer will perform a quarterly inspection of nurse¿s documentation to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018.
[Individual #1's March 2018 medication administration records had all medications logged as administered. Immediately and continuing at least monthly, the Nurse coordinator shall audit all individuals' current medication administration record, medications and doctors orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits shall be kept. Staff person's certified to administered medications shall be reeducated by a certified medication trainer in medication administration and documentation if medication errors or documentation errors are found during audits or at any other time. Documentation of all medication trainings shall be kept. (AS 3/23/18)] |
03/09/2018
| Implemented |
| 6400.181(d) | The program specialist did not sign Individual #1's assessment completed 9/1/17. | The program specialist shall sign and date the assessment. | Persons Responsible-Program Specialist & Program Coordinator Action-Moving forward, NF program specialist signed and dated the assessment. NF program specialist will sign and date future assessments.Protocol-Program Specialist and Program Coordinator are updating functional assessment tool. PS & PC will keep a tracking system of dates when assessments need signed & filled according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Compliance officer will perform a quarterly inspection of FAT¿s 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. [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)] |
02/11/2018
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment completed 9/1/17 did not include strengths, needs or preferences. This section was blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Persons Responsible-Program Specialist & Program Coordinator Action-NF included the functional strengths, needs and preferences of the individual in the assessment. Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator will implement the tool at all individuals to ensure the strengths, needs and preferences are covered and all other areas according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9.
Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). Immediately, the CEO shall educate the Program Specialist of the required information |
03/09/2018
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment completed 9/1/17 did not have likes, dislikes and interests . This section was blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Persons Responsible-Program Specialist & Program Coordinator Action-NF filled out the likes, dislikes and interest of the individual assessment. Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator will implement the tool at all individuals include the following information: The likes, dislikes and interest of the individual according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's assessment completed 9/1/17 did not include communication. This section was blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Persons Responsible-Program Specialist & Program Coordinator Action-NF included the communication to the individual in the assessment.Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator will implement the tool at all individuals include the following information: The individual¿s current level of performance and progress in the following areas: Communication according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT.
All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(3)(iii) | Individual #1's assessment completed 9/1/17 did not include personal adjustment. This section was blank. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Persons Responsible-Program Specialist & Program Coordinator Action-NF included the individual¿s need for supervision in the assessment. Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator will implement the tool at all the individual's current level of performance and progress in the following areas: Personal adjustment according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's assessment completed 9/1/17 did not include needs with or without assistance. This section was blank. | 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. | Persons Responsible-Program Specialist & Program Coordinator Action-NF included the individual¿s need for supervision in the assessment. Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator 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 according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment completed 9/1/17 did not include need for supervision. This section was blank. | The assessment must include the following information: The individual's need for supervision.
| Persons Responsible-Program Specialist & Program Coordinator Action-NF included the individual¿s need for supervision in the assessment. Protocol-Program Specialist and Program Coordinator are revamping a new functional assessment tool. In following, the Program Coordinator 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 according to regulations are covered. The staff will be trained to monitor FAT to recommend updates to the Program Specialist when changes occur with the individuals that needs updated to the FAT. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection of FAT¿s 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment completed 9/1/17 did not include self-administration of medications. This section was blank. | The assessment must include the following information: The individual's ability to self-administer medications. | [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)] |
03/09/2018
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment completed 9/1/17 did not include ability to avoid poisonous materials. This section was blank. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | NF included the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials in the assessment. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)(7) | Individual #1's assessment completed 9/1/17 did not include knowledge of heat sources. This section was blank. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | NF included the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated in the assessment. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)(8) | Individual #1's assessment completed 9/1/17 did not include ability to evacuate in a fire. This section was blank. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | NF included the individual's ability to evacuate in the event of a fire in the assessment. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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)(9) | Individual #1's assessment completed 9/1/17 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. | NF included the individual's disability, including functional and medical limitations in the assessment. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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 9/1/17 did not include recommendations. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | NF included the individual's recommendations for specific areas of training, programming and services in the assessment. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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 9/1/17 did not 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. | NF included 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. [Individual #1's assessment was updated on 3/1/18 by the Acting Program specialist (updates were dated 6/20/17). 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(f) | The program specialist did not provide Individual #1's assessment completed 9/1/17 to the SC and plan team members. | (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).
| NF program specialist will provide Individual #1's assessment completed 9/1/17 to the SC and plan team members. [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 provide Individual #1' assessment to the plan team members. Immediately, the Program specialist shall develop and implement a tracking system to ensure the plan team members are provided all individuals' assessments, timely. At least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and the correspondence documentation to ensure the program specialist provided all individuals' assessments to all plan team members, timely. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Not Implemented |
| 6400.186(a) | The program specialist did not completed ISP reviews for Individual #1, date of admission 7/1/17. | 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. | NF program specialist will 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. [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 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 individual 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 the 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. | NF program specialist shall notify the plan team members of the option to decline the ISP review documentation and keep record of notification. [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 team 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 |
| 6400.213(1)(i) | Individual #1's records did not include identifying marks or 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.
| 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 was added. [individual #1's record was updated to identify marks and religious affiliation. Immediately, upon admission and at least quarterly for 1 year, the CEO or designated management staff person shall audit all individuals' records to ensure all required information as per 6400.213(1)(14) is included in all individuals' records. Missing information shall be immediately obtained. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |
| 6400.213(10)(i) | The record for Individual #1, date of admission 7/1/17 did not included the ISP review signature page. | Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: ISP review signature sheets. | Not Forgotten will ensure documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: ISP review signature sheets will be completed. [Individual #1 ISP review signature sheet, date 12/17/17 was located in the agency office. Immediately, Individual #1 ISP review signature sheet, date 12/17/17 shall be put in Individual #1's record. [individual #1's record was updated to identify marks and religious affiliation. Immediately, upon admission and at least quarterly for 1 year, the CEO or designated management staff person shall audit all individuals' records to ensure all required information as per 6400.213(1)(14) is included in all individuals' records. Missing information shall be immediately obtained. Documentation of the audits shall be kept. (AS 3/23/18)] |
01/29/2018
| Implemented |