Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.59(b) | The hot water temperature at the sink in the men's restroom measured 123.6 degrees Fahrenheit, at 2:45 PM. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The Program Specialist with preform weekly temperature checks, for 3 months and monthly thereafter, in each restroom to ensure that the temperature does not exceed 120°F. The temperature will be recorded and maintained at the licensed facility. [The hot water was measured in the male restroom with the following measurements on 9/15/17, 122.4; 9/22/17, 116.2; 9/25/17, 103.4. The hot water was measured in the female restroom with the following measurements on 9/15/17, 121.8; 9/22/17, 115.3; 9/25/17, 102.5. At least monthly for one year, the CEO shall review the hot water temperature checks to ensure the hot water temperatures in areas accessible to individual do not exceed 120°F. (AS 10/2/17)] |
12/11/2017
| Implemented |
2380.91(a) | Individual #1, date of admission 11-7-16, Individual #2, date of admission 8-3-17, Individual #3, date of admission 11-7-16, Individual #4, date of admission 3-27-17, Individual #5, date of admission 5-4-17, Individual #6, date of admission 11-7-16, Individual #7, date of admission 11-7-16 and Individual #8, date of admission 11-7-16 were not instructed upon initial admission in general firesafety, 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 facility. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility. | Ongoing the Program Specialist will use a sign in sheet for the day of fire safety training in order to properly document that each individual was instructed in general fire safety, evacuation procedures, responsibilities during fire drills, and the designated meeting place outside the building. This will be done upon admission and annually thereafter. The sign in sheet will be maintained in the Fire Drill chart at the licensed facility. [On 9/18/17, the program specialist completed a fire safety training with 23 individuals. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are instructed in fire safety as required upon admission and annually. Documentation of the trainings and tracking system shall be kept and reviewed by CEO or designee at least quarterly for 1 year. (AS 10/2/17)] |
12/11/2017
| Implemented |
2380.111(c)(3) | Individual #1's physical examination, dated 3-25-17, did not include immunizations. Individual #5's physical examination, dated 12-19-16, did not include immunizations. Individual #6's physical examination, dated 5-25-17, did not include immunizations. The most recent immunizations completed for Individual #7 were 7-24-06. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including immunizations. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/10/2017
| Implemented |
2380.111(c)(4) | Individual #3's physical examination, dated 1-17-17 did not include vision and hearing screenings. Individual #4's physical examination, dated 4-24-17 did not include vision and hearing screenings. Individual #7's physical examination, dated 3-28-17 did not include vision and hearing screenings. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including vision and hearing screening. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.111(c)(7) | Individual #5's physical examination, dated 12-19-16 did not include an assessment of the individual's health maintenance needs. | 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. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.111(c)(8) | Individual #1's physical examination, dated 3-25-17 did not include physical limitations of the individual. Individual #5's physical examination, dated 12-19-16 did not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including physical limitations of the individual.
By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.111(c)(9) | Individual #5's physical examination, dated 12-19-16 did not include allergies or contraindicated medications. Individual #7's physical examination, dated 3-28-17 did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medication. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including allergies or contraindicated medications. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.111(c)(10) | Individual #5's physical examination, dated 12-19-16 did not include medical information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including medical information pertinent to diagnosis and treatment in case of an emergency. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.111(c)(11) | Individual #3's physical examination, dated 1-17-17 did not include special instructions for an individual's diet. Individual #5's physical examination, dated 12-19-16 did not include special instructions for an individual's diet. Individual #6's physical examination, dated 5-25-17 did not include special instructions for an individual's diet. Individual #7's physical examination, dated 3-28-17 did not include special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual's diet. | For the survey sample and all others, by 9/29/2017, the Program Specialist will review the physical on file. The Program Specialist will develop a letter to be sent to the individual if it is determined that their physical is out of compliance. The letter will include a copy of the current physical form to be updated by the individual¿s doctor to include any missing information, including special instructions for an individual¿s diet. By 11/1/2017, the Director of IDD Services will review the file to ensure that all physical updates have been received. Ongoing, at the intake meeting, the individual¿s team will be made aware that the individual will not be able to start until a fully complaint physical has been obtained and delivered to the agency. The Program Specialist will review all incoming physicals for completeness and compliance. The Director of IDD Services will review all incoming physicals at intake for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. |
12/11/2017
| Implemented |
2380.113(a) | Direct Service Worker #1, date of hire 8-9-17 did not have a physical examination. Direct Service Worker #2, date of hire 3-6-17 did not have a physical examination. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | For the survey sample and all others, by 9/22/2017, HR files will be reviewed by the Director of IDD Services. If it is determined that a staff physical is out of compliance, the staff member will be required to obtain a physical as soon as possible, not to exceed two weeks. Ongoing staff members are required to have a physical examination prior to working and every 2 years thereafter and proper forms documenting the examinations will be kept on file. For any new hire a physical will be obtain at new hire orientation. If a physical is not provided, the staff will not work in ration until the physical is submitted. The physical will be maintained in the HR file at the administration office.[Direct Service Worker #1 had a physical examination completed 8/10/17. Direct Service Worker #2 had a physical examination completed 1/14/17. Immediately, the Director shall develop and implement a tracking, notification and record keeping system to ensure all 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 persons, have a physical examination within 12 months prior to employment and every 2 years thereafter and documentation is maintained and available upon request by the Department. (AS 10/2/17)] |
10/13/2017
| Implemented |
2380.173(1)(ii) | The records for Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Individual #6, Individual #7 and Individual #8 did not include identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The Director of IDD Services will, by 9/22/2017, review regulations and update the Client Emergency Information Sheet to include all required information including race, height, weight, color of hair, and identifying marks. By 9/29/2017 the Program Specialist will ensure each individual has been provided an updated copy of the Client Emergency Information Sheet to be updated and submitted to the Program Specialist. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each Client Emergency Information Sheet has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. [The records for Individual #1, Individual #2, Individual #3, Individual #4, Individual #5, Individual #6, Individual #7 and Individual #8 were updated to included identify marks. Within 30 days of receipt of the plan of correction, the CEO or director shall review with the program specialist(s) the responsibilities of the program specialist position as per 2380.33(b)(1)-(19) and the requirements of individuals' records as per 2380.173(1)-(11) the aforementioned procedures to ensure all individuals' records include the required information. Documentation of the trainings shall be kept. (AS 10/2/17)] |
09/10/2018
| Implemented |
2380.181(a) | Individual #7, admitted on 11-7-16 did not have an initial assessment. The most recent assessment for Individual #8 was completed on 5-16-16. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | For the survey sample and all others, by 9/22/2017, the program specialist will review all assessments and update as necessary. By 10/1/2017, the Director of IDD Services will review the assessments for completeness. Ongoing, the Program Specialist will complete an initial assessment for individuals within 60 calendar days after admission and annually thereafter. The assessments will be sent to the team members along with a cover letter and both documents will be filed in the respective charts. The Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each assessment has been updated as needed and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. [Individual #1's assessment was completed 9/18/17. Individual #2's assessment was completed 9/18/17. Within 30 days of receipt of the plan of correction, the CEO or director shall review with the program specialist(s) the responsibilities of the position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. (AS 10/2/17)] |
10/01/2017
| Implemented |
2380.181(f) | The program specialist did not provide Individual #1's assessment completed 1-6-17 to the plan team members for an annual ISP meeting on 5-5-17. The program specialist did not provide Individual #8's assessment completed 5-16-16 to the plan team members for an annual ISP meeting 3-9-17. | The program specialist shall provide the assessment to the SC or plan lead, 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). | For the survey sample and all others, by 9/29/2017, a letter and assessment will be sent to all team members if it determined by review that it hasn¿t yet been sent per regulation requirements. The Program Specialist will develop the letter and assessment as needed per the appropriate review cycle. The Director of IDD Services will review the letters and assessment to ensure all team members are accounted for. The Director level review will happen monthly for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility. Immediately, the program specialist will review the most recent correspondence documentation showing the program specialist provided assessments to all plan team members as required and documentation is maintained. If during the review process the Director finds assessments not provided to plan team members as required the aforementioned review process shall continue quarterly for 1 year. [Individual #8's assessment completed 9/18/17 was sent to the plan team members on 9/22/17. Within 30 days of receipt of the plan of correction, the CEO or director shall review with the program specialist(s) the responsibilities of the position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. (AS 10/2/17)] |
03/12/2018
| Implemented |
2380.186(a) | The most recent ISP review for Individual #6 was 2-6-17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | The Program Specialist will complete an ISP review for Individual #6 by 9/22/2017 and every three months thereafter per the previous cycle. Ongoing, the Program Specialist will conduct a chart review of 25% of charts, every 90 days, to ensure each individual¿s ISP has been reviewed each 90 days and all charts will be reviewed at least annually. The chart review form will be submitted to the Director of IDD Services for review and maintained at the administration office. [Individual #6 had an ISP review completed 8/4/17. (AS 10/2/17)] |
12/22/2017
| Implemented |
2380.186(d) | The program specialist did not provide Individual #1's ISP reviews ending on 2-6-17, 5-8-17 and 8-4-17 to the plan team members. The program specialist did not provide Individual #3's ISP reviews ending on 2-6-17 and 5-5-17 to the plan team members. The program specialist did not provide Individual #4's ISP review ending on 6-29-17 to the plan team members. The program specialist did not provide Individual #7's ISP reviews ending on 2-6-17 and 5-5-17 to the plan team members. The program specialist did not provide Individual #8's ISP reviews ending on 2-8-17 and 5-5-17 to the plan team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | For the survey sample, the Program Specialist will develop a letter and send the missed ISP reviews to the respective team members. Ongoing, the Program Specialist will develop the letter and supporting documentation as needed per the appropriate review cycle. The Director of IDD Services will review the letters and supporting documentation to ensure all team members are accounted for. The Director level review will happen monthly for three month and at the end of the following quarter to ensure the system has maintained its purpose. The Director level review will be indicated by signature and a copy will be maintained at the licensed facility.[Within 30 days of receipt of the plan of correction, the CEO or director shall review with the program specialist(s) the responsibilities of the position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Immediately, the director will review the most recent correspondence documentation showing the program specialist provide quarterly reviews to all plan team members as required and documentation is maintained. If during the review process the Director finds quarterlies not provided to plan team members as required the aforementioned review process shall continue quarterly for 1 year. Documentation of all audits shall be kept. (AS 10/2/17)] |
09/10/2018
| Implemented |
2380.186(e) | The program specialist did not notify the plan team members for Individual #1, Individual #4 and Individual #8 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. | For the survey sample and all others, by 10/1/2017, the Program Specialist will develop a form to notify the plan team members of the option to decline the ISP review documentation. The form will be provided to all team members by email and/or mail. As team members return the form, it will be reviewed by the Program Specialist for completeness and maintained at the licensed facility. By 11/1/2017, the Director of IDD Services will review files to ensure all team members have been accounted for. Ongoing, forms will be mailed out annually to ensure team members are accounted for. |
11/01/2017
| Implemented |