| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's record contained an unsigned copy of individual 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. | There was an oversight during the signing of admission paperwork for Individual #1. Going forward, a second staff will go over admission paperwork to ensure nothing was missed. |
12/06/2017
| Implemented |
| 6400.46(g) | The fire saftey training for staff #2 was not conducted by an expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | Staff #2 was trained by the CEO, whom was trained by an expect. Documentation of CEO's training was send to inspector via email on 11/8/17 per inspector's request. |
11/08/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's annual physical dated 1/6/17 indicated that a TB/PPD test was conducted, however it did not list the results of the test or when the test may have been read. | 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. | Annual physical reviewed during annual inspection was done prior to individual #1 enrollment into our program. A new TB/PPD test was order and administered on 12/06/2017 and reading expected on 12/08/17. Going forward, all incoming physical would go through a careful scrutiny for licensing compliance. Results of newly ordered TP/PPD will be forwarded to inspector by 12/14/2017 |
12/14/2017
| Implemented |
| 6400.141(c)(13) | On individual 3's annual physical dated 1/6/17, the area to list allergies was left blank. | The physical examination shall include: Allergies or contraindicated medications. | Annual physical reviewed during annual inspection was done prior to individual #1 enrollment into our program. Individual #1's PCP will test for allergies and attest and respond to the part of the physical not answered relating to allergies. She has refused to do a new physical. The PCP's response to individual #1's allergies or the lack of will be forwarded to the inspector by 12/14/2017. Going forward, we would scrutinize incoming physicals for compliance. |
12/14/2017
| Implemented |
| 6400.151(a) | Staff #2 did not have a physical on record since the date of hire, 6/1/17. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff 2 had a physical but was not in the file at the time. Inspector was furnished with the record via email on 11/8/17 per his request. |
11/08/2017
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 6/9/17 and did not have an assessment completed as of the date of this inspection. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | We were under the impression that assessment was to be made a year after the individual is enrolled into our program. An assessment is been made now to be in compliance and a copy will be send to the inspector within 7 business day from today. Going forward, we will create a reminder scheduled to ensured that every new enroll is assessed within 60 days of enrollment. |
12/14/2017
| Implemented |
| 6400.186(c)(1) | Individual #1's ISP dated 6/5/17 was not reviewed monthly since admission on 6/9/17. | 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. | PCS's program specialist failed to complete and submit monthly ISP reviews. Specialist has since been terminated. PCS has since put a schedule in place for monthly and quarterly ISP reviews. Going forward, Automatic reminders via email and text messages would signal program specialist and CEO on ISP monthly and quarterlies deliverables. |
12/06/2017
| Implemented |