| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00220851
|
Renewal
|
02/28/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Direct Service Worker #1, date of hire 12/6/2022 had initial physical examination completed 12/1/2021. | 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. | KACS mangement team will have direct service worker have new physical completed in order to maintain employment and to regain compliance with this regulation. |
04/28/2023
| Implemented |
| 6400.181(a) | Individual #1 had an assessment completed 8/12/2021 and then again 9/13/2022. | 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. | KACS CEO will meet with KACS Program specialist to discuss proper timing of all individual assesments. |
04/28/2023
| Implemented |
|
|
|
SIN-00214994
|
Unannounced Monitoring
|
11/02/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | During the inspection conducted 11/02/2022 the exhaust fan on the ceiling of Individual #1's bathroom was inoperable and contained no other forms of ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| KACS program specialist will put in a service request to have ventilation repaired. |
12/28/2022
| Implemented |
| 6400.171 | During the inspection conducted 11/02/2022 there was a small reusable Tupperware container filled approximately 2/3rds of the way with grease and food particles on the kitchen counter. | Food shall be protected from contamination while being stored, prepared, transported and served.
| KACS program specialist has thrown out grease in Tupperware container. |
12/28/2022
| Implemented |
|
|
|
SIN-00204766
|
Unannounced Monitoring
|
05/05/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | During the inspection conducted 5/05/2022, there was an electrical outlet in Individual #2's bedroom, which was protruding out of the wall and exposing electrical wires, on the wall to the left of the bedroom door | Floors, walls, ceilings and other surfaces shall be free of hazards. | KACS Director will have private contractor come and repair the exposed wires and outlet. |
06/11/2022
| Implemented |
| 6400.166(a)(4) | During the inspection conducted 5/05/2022 Individual #1 is prescribed Docusate Sodium 50mg/ Sennosides USP 8.6mg tablet. Individual #1's May 2022 medication administration record listed the medication name as Stool Softener Stim Lax tablet 8.6-50mg. Individual #1 is prescribed Polyethylene Glycol 3350 510gm, take 17 grams dissolved in water by g-tube as needed. During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | KACS program specialistwill input the medication details on the MAR; KACS program specialist will take medication to the pharmacy to be repackaged. |
06/11/2022
| Implemented |
| 6400.166(a)(5) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the strength of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | KACS program specialist will update the MAR information to regain compliance of medication |
06/11/2022
| Implemented |
| 6400.166(a)(6) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the dosage form. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | KACS program specialist will update MAR information to include dosage form |
06/11/2022
| Implemented |
| 6400.166(a)(7) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the dose of medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | KACS program specialist will update MAR information to include the dose of the listed medication. |
06/11/2022
| Implemented |
| 6400.166(a)(8) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | KACS program specialist will update MAR information to include route of listed medication |
06/11/2022
| Implemented |
| 6400.166(a)(9) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | KACS nurse will update MAR information on liste medication to include the frequency of administration |
06/11/2022
| Implemented |
| 6400.166(a)(11) | During the inspection conducted 5/05/2022 Individual #1's Polyethylene Glycol 3350 510gm was not listed on the individual's May 2022 medication administration record, including the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | KACS program specialist will update MAR information to include the purpose for the medication listed. |
06/11/2022
| Implemented |
|
|
|
SIN-00189764
|
Unannounced Monitoring
|
06/16/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | .On 6/24/21 the agency did not provide the Department access to following items requested: contact information for the registered nurse who trained staff on Individual #1's GTube care and medication administration, and Individual #1's rep payee documentation. On 6/28/21 the agency did not provide the Department access to Individual #1's most recent Gastroenterology appointment documentation. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The Director has overseen training for executive staff and staff with supervisory
roles to ensure that authorized agents of the Department have full access to the
facility or agency and its records during both announced and unannounced
inspections. The director has trained the executive staff to included the phone number and address on all contracted staff forms. |
09/01/2021
| Implemented |
| 6400.166(a)(8) | .Individual #2 is prescribed Senna 8.6mg, take 2 tablets by mouth twice daily; the Medication administration record for June 2021 did not include the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The individual¿s medication documentation error was corrected.
The Director has hired a new training staff member who will ensure all Staff are
trained and capable of operating The Electronic MAR System through Therap. |
09/01/2021
| Implemented |
| 6400.166(a)(11) | Individual #2 is prescribed Polyethylene Glycol 3350 Powder, dissolve 17gm in 8oz of water as needed for constipation; the Medication administration record for June 2021 did not include the purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The individual¿s medication documentation error was corrected.
The Director has hired a new training staff member who will ensure all Staff are
trained and capable of operating The Electronic MAR System through Therap. |
09/01/2021
| Implemented |
|
|
|
SIN-00187295
|
Renewal
|
04/22/2021
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The provider is representative payee for Individual #1 and has no record of financial resources, including dates and amounts of deposits and withdrawals. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Director has updated the financial record storage procedures. The individual has agreed to give
the provider access to monthly bank statements and a paper leger has been placed in the
residence to log any cash on hand. The individual and staff have been informed to store all
receipts in the folder which is stored with the cash on hand leger. |
05/17/2021
| Not Implemented |
| 6400.81(k)(6) | During the home inspection on 4/23/2020, Individual #2 did not have a mirror in their bedroom. | In bedrooms, each individual shall have the following: A mirror. | During the inspection on 04/23/2021, the individual noted did have a mirror in his bedroom. The
mirror was located on the floor in front of his bed and at the time of the inspection. Although
several items were In front of the mirror per the individual request for a second television which
he plays video games. The individual was informed a refusal must be signed he if wanted to
continue to keep the mirror covered. |
05/17/2021
| Implemented |
| 6400.141(a) | Individual #1 had a physical examination completed 1/30/2020 and then again 2/16/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Several appointments were canceled or missed due to weather and the individual¿s concern for
COVID 19. The Program Special has been tasked with documenting any future appointments
refused by the individuals and issuing appointments are completed within 12 months of the
previous. |
05/17/2021
| Not Implemented |
| 6400.141(c)(4) | Individual #1, date of admission 3/28/2017, had an hearing screening completed 2/16/2021. There was no documentation of a previous hearing screening, therefore compliance could not be measured. Individual #1 had a vision screening completed 2/16/2021 and then again 4/17/2021. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Special has been tasked with documenting all appointments and refusals by the
individual. |
05/17/2021
| Not Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 3/28/2017, had an initial Tuberculin skin test by Mantoux method completed 12/19/2020. There was no documentation of a previous Tuberculin skin test, therefore compliance could not be measured. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Program Special has been tasked with documenting all appointments and refusals by the
individuals. The PS and House Supervisor will ensure a standardized Individual Annual Physical
Exam Form is used and completely filled out by the appropriate medical personnel before
leaving the appointment. |
05/17/2021
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 2/16/2021 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Special has been tasked with documenting all appointments and refusals by the
individuals. The PS and House Supervisor will ensure a standardized Individual Annual Physical
Exam Form is used and completely filled out by the appropriate medical personnel before
leaving the appointment. |
05/17/2021
| Not Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed 6/18/2018 and then again 4/13/2021. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Program Special has been tasked with documenting all appointments and refusals by the
individuals. The PS and House Supervisor will ensure a standardized Individual Annual Dental
Exam Form is used and completely filled out by the appropriate medical personnel before
leaving the appointment. |
05/17/2021
| Not Implemented |
| 6400.143(a) | Individual #1 refused a prostate examination 1/01/2020 and then again 1/02/2021, and there is no record of continued attempts to train the individual about the need for the prostate examination. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The Program Special has been tasked with documenting all appointments and refusals by the
individuals. The PS and House Supervisor will continue to provide information packets for any
refused examinations. |
05/17/2021
| Not Implemented |
| 6400.144 | Individual #1's physical examination completed 2/16/2021 states a dysphagia screening is recommended for the individual and there is no record of one being scheduled or provided {repeat violation 12-23-2020}. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The dysphagia screening was perilously scheduled. The Program Special has been tasked with
documenting all appointments and refusals by the individuals. |
05/17/2021
| Not Implemented |
| 6400.166(d) | Individual #1 is prescribed Hydrochlorothiazide 21.5mg, with instructions to take capsule by mouth once daily. The medication is being administered through the individual's peg tube. | The directions of the prescriber shall be followed. | The induvial medication is being administered correctly through the individuals¿ peg tub. The
directions of the prescriber were corrected and are being followed. |
05/17/2021
| Not Implemented |
| 6400.169(a) | Individual #1 is prescribed Diazepam 2mg, with instructions to crush medication and give through peg tube. There is no record of staff being trained on administering medications via feeding tube, by a medical professional | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff had been trained by a medical professional and documentation of the training records will
be retained by HR personnel. |
05/17/2021
| Not Implemented |
|
|
|
SIN-00185371
|
Unannounced Monitoring
|
03/25/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | As of 2:05PM on 3/26/21, The agency did not provide individual, staff, or fire drill records requested on 3/25/21 at 11:45AM, during the unannounced monitoring inspection (Repeat Violation 12/21/20 et al). | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The facility or agency has added additional staffing and provided the additional staff training on the requirements during the unannounced monitoring inspection. The facility or agency has implement a documentation logging system that uploads all the required documentation and provides access to the facility or agency individual, staff as needed per any future announced or unannounced monitoring inspection. |
04/30/2021
| Implemented |
|
|
|
SIN-00181041
|
Renewal
|
12/21/2020
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | The fire drills held from April 2020 to December 2020 were all conducted on the sixth of the month; 4/06/2020, 5/06/2020, 6/06/2020, 7/06/2020, 8/06/2020, 9/06/2020, 10/06/2020, 11/06/2020 and 12/06/2020.(Repeat Violation 3/10/20) | An unannounced fire drill shall be held at least once a month. | Keliser Adult Care Services LLC will conduct an unannounced fire drill at least once a month. The house Supervisor will monitor the implementation of this plan of correction to ensure it is completed within a timely manner on different days of the month.[Fire drill was completed 1/18/21. At least monthly for one year then continuing quarterly, the CEO or designee will audit all fire drill records to ensure fire drills are conducted on different days of each month. Immediately, the CEO or designated management staff will train all staff responsible for conducting fire drills on the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] |
01/15/2021
| Not Implemented |
| 6400.144 | Individual #2's physical examination completed 3/13/2020 prescribed a mechanical soft diet to Individual #2. Individual #2's dental consultation form for services on 1/13/2020 reads "Dr. recommends···and suggests a modified pureed diet···and his food needs to be cut into small pieces." The agency did not follow the prescriber's order for the diet or follow up to inquire about the change in diet and continued to provide a diet with chopped foods to Individual #2. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The individuals doctor made a documentation error on both of his annual physicals. The PMS attends the individuals doctor appointments with the individuals mother. The PMS did not address the diet restrictions as she attended the appointments. The individuals mother also informed the agency the individual only needed his food cut up into small pieces. At the time of inspection, the agency provided inspectors with a letter from the individuals doctor indicating it was a documentation error. The PMS was not sure about how to address this issue as the doctor never said anything about the diet other than cut fine and neither did the doctor. The doctors note was provided to the inspectors at time of inspection. The PMS and Director will supervise all individuals diet recommendations upon admission and annually thereafter to ensure the correct documentation is on the individuals records and will ensure the individuals SC clarifies any confusion moving forward.[Immediately, the CEO or designated management staff shall train all staff responsible for completing physical examinations on the requirements of the chapter. Immediately and at least quarterly for at least one year, the CEO or designee will audit all individuals' physical examinations and ensure that all information is accurate. The agency will contact the physician to clarify any changes or discrepancies. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] |
12/23/2020
| Not Implemented |
| 6400.18(a)(9) | On 7/02/2020, Individual #1's feeding tube was displaced during a shower requiring Individual #1 to be seen in the emergency department of a hospital. The agency reported the injury requiring treatment beyond first aid incident (8714048) in the Department's information management system, Enterprise Incident Management Systems on 7/12/2020. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| Keliser Adult Care Services LLC will ensure that incidents will be reported within 24 hours of discovery. The team has also hired a designated EIM person to handle and complete all incidents. The Director will cross reference all incidents to ensure they are completed in a timely manner.[The individuals record was reviewed on 2/5/21 and did include identifying marks. At least quarterly for on year, the CEO or designee will audit all Individuals' records to ensure they include identifying marks. Documentation of all audits shall be kept (DPOC by RM, HSLS on 2/16/2021)] |
01/15/2021
| Not Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 8/12/20. The rights document did not include the following rights: 6400.32e through 6400.32i, to choose, accept risks, refusal and control the individual's schedule, activities and services, privacy and access to person and possessions; 6400.32n, unrestricted and private access to telecommunications; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, locking doors in bedrooms and in the home, access to food at any time, and making healthcare decisions. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Keliser Adult Care services will ensure that the individuals and persons designated by the individual are informed and explained their rights, and the process to report a rights violation, upon admission to the home and annually thereafter. The Program Specialist will verify that all individuals are informed of their rights and will ensure they understand how to report a rights violation.
The Director will cross reference all individual rights to ensure they are compliant with the regulations and they individuals are informed of what they are and how to report a rights violation.[Individual was informed of their updated rights on 12/23/2020. Immediately, the CEO or designated management staff will develop a tracking system to ensure individuals are informed of their rights upon admission and annually thereafter. Quarterly for at least one year, the CEO or designee will audit all individuals' records to ensure they have been informed of their rights upon admission and annually thereafter. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 2/16/2021)] |
01/15/2021
| Not Implemented |
|
|
|
SIN-00172281
|
Renewal
|
03/10/2020
|
Non Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | The agency retains receipts for purchases by the individual or by the staff on behalf of the individual exceeding $15.00. The agency's written policy regarding management of individual's funds indicates that the agency will retain all receipts for purchases made by the individual or by staff on behalf of the individual. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | Keliser Adult Care Services has established a fiscal compliance policy that outlines the procedures for the protection and adequate accounting of individual funds and property for the individual concerning the use of funds and property. The agency has financial ledgers, accounting statements, and receipts for all purchases that exceed $15.00 per regulatory standards. [Immediately, the CEO and others involved in supporting the individuals in their financial needs shall review and revise the agency written policy that that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property to ensure all requirements are addressed. At least monthly, the CEO or designee shall audit all financial records for the individuals to ensure the written policy is implement and documentation as required is maintained. Documentation of all financial audits shall be kept. (DPOC by AES, HSLS on 7/10/20)] |
04/15/2020
| Not Implemented |
| 6400.22(e)(1) | A separate record of financial resources, including the dates and amounts of deposits and withdrawals was not maintained for Individual #2. The agency is Individual #2's Representative Payee. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals.[Immediately, the CEO and others involved in supporting the individuals in their financial needs shall review and revise the agency written policy that that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property to ensure all requirements are addressed. At least monthly, the CEO or designee shall audit all financial records for the individuals to ensure the written policy is implement and documentation as required is maintained. Documentation of all financial audits shall be kept. (DPOC by AES, HSLS on 7/10/20)] |
04/15/2020
| Not Implemented |
| 6400.22(e)(2) | Chief Executive Officer #1 and the Program Specialist #2 report that money is given directly to the Individual #2, monthly. There is not a record that funds were given directly to Individual #2. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | Keliser Adult Care Services just completed the first fiscal compliance audit. Keliser Adult Care Services keeps records and signatures on file of all financial exchanges between all individuals and the agency.[Immediately, the CEO and others involved in supporting the individuals in their financial needs shall review and revise the agency written policy that that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property to ensure all requirements are addressed. At least monthly, the CEO or designee shall audit all financial records for the individuals to ensure the written policy is implement and documentation as required is maintained. Documentation of all financial audits shall be kept. (DPOC by AES, HSLS on 7/10/20)] |
04/15/2020
| Not Implemented |
| 6400.62(a) | At 12:12PM, a 3.12 qt full bottle of Pinesol 4x cleaning action Multi-surface Cleaner, with the instructions to contact Poison Control or seek medical advice if swallowed, was found unlocked, unattended, and accessible under the kitchen sink. Individual #1's Assessment, dated 1/24/2020, indicates they are not able to independently use or avoid poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Keliser Adult Care Services already has a policy in place that keeps all poisonous materials locked away from individuals. All staff was retrained on hazardous materials policy and management will check to ensure all poisonous materials are kept and remain locked up.[On 6/25/20, there were not any poisonous materials accessible to individuals. Poisonous materials were locked in a closet. Weekly checks of the homes for poisonous materials is being kept. (DPOC by AES,HSLS on 7/6/20)] |
04/15/2020
| Implemented |
| 6400.112(e) | A fire drill was held during sleeping hours on 2/19/19 and then again on 1/6/2020 [Repeat violation 3/19/19, et. al. and 4/17/18]. | A fire drill shall be held during sleeping hours at least every 6 months. | Keliser Adult Care Services retrained staff on the fire drill policy. The executive team will monitor house supervisor during drills to ensure fire drills will be held during sleep hours every 6 months. [Documentation of a fire drill during sleeping hours on May 6, 2020 was provided to the Department on 7/7/20. Immediately, the CEO or designee shall train all staff persons responsible for conducting, participating and observing fire drills of the requirements of fire drills as per 6400.112a-112h. Documentation of the trainings shall be kept. At least monthly for 1 year, and continuing at least quarterly, the CEO or designee shall audit all fire drill records to ensure fire drills are held and documented as required. (DPOC by AES,HSLS on 7/6/20)] |
04/15/2020
| Implemented |
| 6400.112(i) | The fire drill conducted 1/6/2020 did not include the use of at least one smoke detector, the fire drill form states "verbal" for the type of alarm used. | A fire alarm or smoke detector shall be set off during each fire drill. | Keliser Adult Care Services retrained staff on the fire drill policy. The executive team will monitor house supervisor during drills to ensure the smoke detector and or fire alarm is used as the alarm type and all documentation is completed correctly to reflect proper execution. [The fire drills held in April, May and June 2020 used the fire alarm in each of the fire drills. Immediately, the CEO or designee shall train all staff persons responsible for conducting, participating and observing fire drills of the requirements of fire drills as per 6400.112a-112h. Documentation of the trainings shall be kept. At least monthly for 1 year, and continuing at least quarterly, the CEO or designee shall audit all fire drill records to ensure fire drills are held and documented as required. (DPOC by AES,HSLS on 7/7/20)] |
04/15/2020
| Implemented |
| 6400.113(a) | Individual #2, date of admission 3/28/17, has not been instructed in fire safety. [Repeat violation 3/9/19, et. al. and 4/17/18]. | 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. | Individual #1 was instructed in fire safety upon admission and completed on an annual basis per regulations. Keliser Adult Care Services will ensure completion of fire safety by documenting everything both electronically and hard copy. [On 7/8/20, the provider submitted to the Department an Individual orientation checklists have subject of fire drill and fire safety completed 3/29/2019 and 1/6/20 for Individual #2. Content of the training not submitted, therefore compliance can not be fully measured. Immediately, the CEO or designee shall develop and implement procedures to ensure all individuals are instructed in fire safety as required and documentation is maintained and available upon request by the Department. (DPOC by AES,HSLS on 7/7/20)] |
04/15/2020
| Not Implemented |
| 6400.181(a) | Individual #2's most recent assessment was completed 2/20/2019. | 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. | Keliser Adult Care Services will ensure that all assessments are completed within 1 year prior to or 60 days after admission to the residential home. The executive team will ensure all assessments are completed within the time frame outlined in the regulations. [Individual #2 had an assessment completed 2/20/2020. Immediately, the CEO or designee shall develop and implement a tracking and updating system and auditing procedures to ensure all individuals' assessments are completed timely with all required information and information is kept current. Documentation of the tracking system and updating system and auditing of assessments shall be kept. (DPOC by AES, HSLS on 7/6/20)] |
04/15/2020
| Implemented |
| 6400.163(h) | Vitamin D3 2,000 Unit tablet, take 1 tablet by mouth daily, prescribed to Individual #1 expired on 12/31/2019.This medication remained in Individual #1's medication box. NYAMYC 100,000 units/gm powder, apply to groin topically twice daily, prescribed to Individual #2 expired on 3/28/18. RA COL-RITE 100 MG capsule, take 2 capsules by mouth daily, prescribed to Individual #2 expired on 5/21/19. RA Acetaminophen 500 mg, take 2 tablets by mouth for 7 days, as needed for pain, prescribed to Individual #2 expired on 7/15/19. RA Ibuprofen 200mg tablet, take 2 tablets every 4-6 hours, as needed for pain, prescribed to Individual #2 expired on 7/15/19. These medications remained in Individual #2's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Keliser Adult Care Services will complete monthly medication checks to ensure that all prescription medications that are discontinued or expired will be destroyed in a safe manner according to federal and state regulations.[On 6/25/20, the medication boxes for Individual #1 and Individual #2 did not contain expired medications. Documentation of aforementioned monthly medication checks shall be kept. Immediately and upon hire, the CEO or designee shall educate all staff persons of the agency's procedures for destroying discontinued or expired medications. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 7/6/20)] |
04/15/2020
| Implemented |
| 6400.166(a)(9) | Diazepam 2 mg, take 2 tablets by mouth 2 times daily, prescribed to Individual #2 was listed on Individual #2's March 2020 Medication Administration Record to be administered 3 times daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Keliser Adult Care Services keeps accurate medication administration records. The executive team will check the medication administration records on a daily basis to ensure accurate completion off all medication administration records. All records will be verified for accurate frequency of administration [Individual #2's June 2020 Medication administration record for Diazepam 2 mg tablets , give 3 times per day 8am, 2Pm and 8Pm continues to be is listed to be scheduled and administered and written on the June MAR as Every day 2 times a day at 8:00AM and 8:00PM. Immediately, continuing at least weekly for 3 months and then continuing at least monthly, the CEO or program specialist and a designee who is certified to administer medication shall audit all individuals' medication administration records, prescribers' orders and medication to ensure all individual are administered medications as prescribed and medications are documented as prescribed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/10/20)] |
04/15/2020
| Not Implemented |
| 6400.166(b) | RA Senna 8.6mg tablet, take 2 tablets by mouth once daily, prescribed to Individual #1 was not initialed as administered at 8:00PM on 2/2/20, 2/3/20, 2/5/20, 2/9/20, 2/10/20, 2/12/20, 2/13/20, 2/16/20, 2/17/20, & 2/26/20. Diazepam 2Mg tablet, take 2 times daily, prescribed to Individual #2 was not initialed as administered at 8:00PM on 3/9/20. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Keliser Adult Care Services keeps accurate medication administration records. The executive team will check the medication administration records on a daily basis to ensure accurate completion off all medication administration records. [Individual #1's June 2020 Medication administration record for Polyethylene glycol 3350 powder list frequency as Twice daily is documented as administered and written on the June MAR as every day and administer 1 time daily without an administration time. Immediately, continuing at least weekly for 3 months and then continuing at least monthly, the CEO or program specialist and a designee who is certified to administer medication shall audit all individuals' medication administration records, prescribers' orders and medication to ensure all individual are administered medications as prescribed and medications are documented as prescribed. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 7/10/20)] |
04/15/2020
| Not Implemented |
|
|
|
SIN-00152054
|
Renewal
|
03/19/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(a) | Individual #2, date of admission 9/20/18 was not informed of the individual's rights. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | Director trained program specialist on having documentation that all individuals are informed of the rights upon admission and annually thereafter. Program Specialist was instructed to have documentation both in paper and electronic copies of records. The program specialist was informed to ensure that parents, advocates, and guardians also receive a copy and sign off stating they have done so. [A signed copy of the documentation of Individual #2's acknowledging receipt of individual rights was provided to the Department. Immediately, upon admission and at least quarterly for 1 year and continuing at least annually, the CEO or designee shall review all individuals' records to ensure all individual have been informed of the individual rights and documentation is maintained and available upon request by the Department. (DPOC by AES, HSLS on 8/8/19)] |
05/15/2019
| 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 telephones in the main bathroom and Individual #2's bedroom. [repeat violation-4/17/18] | 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.
| Director trained program specialist on ensuring 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. Program Specialist put all phone numbers near the phones and taped on the back of the cordless handsets. [Immediately, the CEO or designee shall educate all staff persons working in community homes of the required phone numbers by all telephones. At least monthly, the CEO or designee shall complete an walk through of all community homes to ensure all physical site requirements are met including that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line. Documentation of the onsite checks shall be kept. (DPOC by AES, HSLS on 8/8/19)] |
05/16/2019
| Implemented |
| 6400.113(a) | Individual #2, date of admission 9/20/18 was not instructed in fire safety. | 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. | Director trained Program Specialist on policy regarding educating consumers on 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 the individuals smoke at the home. Program Specialist was instructed to make sure that upon completion of the training all consumers sign indicating they received the training at time of admission and continually. [Individual #2 was instructed in fire safety and was documented as completed on 9/20/18. Immediately, upon admission and at least quarterly for 1 year and continuing at least annually, the CEO or designee shall review all individuals' records to ensure all individual have been instructed in fire safety as required and documentation is maintained and available upon request by the Department. (DPOC by AES, HSLS on 8/8/19)] |
05/15/2019
| Implemented |
| 6400.171 | There was an uncovered, clear, plastic cup, half full with a red liquid and a straw in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Director re-trained all staff on company policy that states all food shall be protected from contamination while being stored, prepared, transported and served. Staff was informed that failure to comply will result in disciplinary action and or termination. [As per agency food storage policy, staff person are required to check the refrigerator at the completion of their shift to ensure food and drink are stored properly and documentation of disposal of contaminated contents. Management staff will complete at least weekly checks of the food to ensure food is protected. (DPOC by AES,HSLS on 8/8/19)] |
05/20/2019
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment completed 3/27/18 to the SC and plan team members. [repeat violation 4/17/18] | (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).
| The Director trained the program specialist on the importance of sending the assessment at least 30 days prior to the ISP meeting. The program specialist was instructed to make copies of proof that the assessment is sent. Program specialist was instructed to keep copies of all records both on paper and electronic. [Copy of email showing assessment was provided to the SC on 11/26/18. At least quarterly for 1 year, the CEO or designee shall audit all the correspondence documentation showing that the program specialist provided all individuals' assessments to all plan team members, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/8/19)] |
05/15/2019
| Implemented |
| 6400.186(b) | Individual #1 did not sign the ISP reviews for review periods from August 2018 through October 2018 and November 2018 through January 2019. Individual #2 did not sign the ISP review for review period from October 2018 through December 2018. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Director re-trained Program Specialist on ensuring all individuals sign and date the signature sheet of all ISP reviews. Director instructed program specialist to keep copies of all reviews and signature pages in a paper and electronic file to always have on record. [Individual #1 signed ISP review from 8/18 to 10/18. Individual #2 signed ISP review from 10/18 to 12/18. Immediately and continuing at least quarterly, the CEO or designated management staff person shall audit all individuals' ISP reviews to ensure the program specialist and individual sign and date the ISP review signature sheet upon review of the ISP. On 5/1/19, the program specialist job description was updated and trained on the duties including completing ISP reviews. Upon hire and at least quarterly for 1 year, the CEO or designee shall audit the program specialist's responsibilities to ensure completion as required. (DPOC by AES,HSLS on 8/8/19)] |
05/15/2019
| Implemented |
|
|
|
SIN-00133200
|
Renewal
|
04/17/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 1/12/18. The expiration of the agency's certification of compliance is 4/11/18. | 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.
| The CEO reviewed the completed self-assessment dated 1/12/18. The assessment was completed 1 day after the expiration of the agency certification of compliance 4/11/18. The CEO reviewed the agency certification of compliance expiration compliance date with the PS and changed the old date in inspection log check list to date prior to 1/12/XX. The CEO will review the self-assessment record 4 months prior with the PS to ensure completed prior to 4/11/XX. [Documentation of the review by the CEO shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.44(b)(10) | The program specialist did not review, sign, and date the monthly documentation for Individual #1, date of admission 3/28/17. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes. | The CEO reviewed the monthly documentation for individual #1 date of admission 3/28/17 finding the monthly documentation not signed by the PS. The CEO reviewed the policy 6400.44(b)(10) with the PS and trained on the requirements. The CEO will review the requirements monthly with the PS to ensure continued compliance. [The program specialist reviewed, signed and dated Individual #1's monthly documentation from January 2018 to July 2018. Immediately, upon hire and continuing at least annually, the CEO shall educate the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least monthly for 3 months and then continuing at least quarterly for 1 year, the CEO shall audit all monthly documentation of individuals' participation and progress toward outcomes to ensure the program specialist is reviewing, signing and dating the monthly documentation for all individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.46(a) | The home did not provide orientation for Direct Service Worker #1, date of hire 10/16/17, and Direct Service Worker #2, date of hire 6/26/17. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | The CEO reviewed the electronic training records for direct service worker #1 hired 10/16/17 and direct service worker #2 hired 6/26/17. The electronic records show orientation training as required by 6400.46(a). The CEO reviewd the requirement of 6400.46(a) with the PS and updated the agency logging process for training records. All training records should be printed and placed in the personal file for all staff. The CEO will review the new process with PS every 3 months to ensure compliance. [Documentation of trainings and reviews shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.46(e) | Direct Service Worker #1, date of hire 10/16/17, did not have training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation. Direct Service Worker #2, date of hire 6/26/17, did not have training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation. | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | The CEO reviewed the electronic training records for direct service worker #1 hired 10/16/17. The electronic records show orientation training as required by 6400.46(e). The CEO reviewed the requirement of 6400.46(e) with the PS and updated the agency logging process for training records. All training records should be printed and placed in the personal file for all staff. The CEO will review the new process with PS every 3 months to ensure compliance.[Immediately, upon hire, annually and at least quarterly for 1 year, the CEO shall audit all staff training records to ensure all staff are trained in all required areas, timely and documentation of trainings are available for review upon request by the Department. Documentation of the audits by the CEO shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.105 | Three empty cardboard television boxes approximately 3 feet long and one empty cardboard walker box approximately 3 feet long were being stored against the furnace in the laundry room in the home. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| The CEO investigated the material stored in the furnace room and laundry area. The furnace installed a electrical furnace with no flame and combustion. The CEO reviewed the 6400.105 requirements with the PS and requested the cardboard be moved from the furnace/laundry room. The CEO will review the requirements with the PS and all staff every months to ensure continued compliance. [Items were removed from laundry room on 4/14/18. CEO trained all staff on 5/3/18 and note was added to the door that nothing is to be stored in this area. At least monthly, a designated staff person shall complete an onsite check of all community homes to ensure Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Documentation of onsite checks shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.111(f) | The fire extinguisher under the sink in the kitchen of the home did not have the date of the inspection on the extinguisher. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The CEO inspected the fire extinguisher finding the inspection label missing. The CEO requested new fire extinguishers be purchased for kitchen. The CEO trained the PS on the requirements for 6400.111(f) and will review the fire extinguisher check off with PS after each approved annually by safety expert check. [On 5/26/18, the fire extinguisher on the second floor of the home was dated 10/17. Immediately and continuing at least quarterly for 1 year, the CEO or designee shall check all fire extinguishers in all community homes to ensure all fire extinguishers have the date of the inspection on the extinguisher. Immediately, the CEO shall develop procedures to ensure all fire extinguishers in the community homes are inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.112(i) | A fire alarm or smoke detector was not set off during each fire drill completed 7/14/17, 8/9/17, 9/9/17, 10/18/17, 11/28/17, 12/25/17, 1/2/18, 2/21/18, 3/16/18. The program manager yells ''fire'' when conducting a fire drill. | A fire alarm or smoke detector shall be set off during each fire drill. | The CEO reviewed the fire drill with the PS concerning setting off during each fire drill. The CEO found setting off the smoke detector or fire alarm caused building fire alarm for 52 residents with the fire department being called to building. The CEO updated the fire drill process to set off a secondary fire alarm or smoke detector not connected to building for a future fire drills. The CEO trained the PS and all staff on the new process for the completion of fire drill. The CEO will review the new process with the PS and staff every 3 months to ensure continued compliance. [Documentation for audits of fire drills by the CEO and PS shall be kept. Within 30 days of receipt of the plan of correction and continuing at least annually, the CEO shall educate all staff person responsible for conducting and review fire drill records of the requirements for fire drills as per 6400.112 (a)-(I). Documentation of the training shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.141(c)(9) | Individual #1's, date of birth 6/13/76, physical examination 2/19/18 did not include a prostate examination. ''Repeated Violation-5/1/17, et al'' | The physical examination shall include: A prostate examination for men 40 years of age or older. | The CEO reviewed the personal files for Individual #1, date of birth 6/13/76 and physical examination 2/19/18. The CEO find a signed waiver to the prostate examination dated 5/17/17 opt not to take the prostate examination. The CEO trained the PS on the requirement for 6400.141(c)(9) and requested updated option not to take prostate examination at time of future physical examination. The CEO will review with PS every 6 months to ensure continued compliance. [Individual #1's doctor completed a written statement on 8/28/2018 stating Individual #1 declined the prostate examination and noted that by current guidelines a test to detect prostate cancer would not be needed until age 50. Due to the notation of the refusal of Individual #1, the agency should implement 6400.143 refusal of treatment procedures as required. Immediately, the CEO shall educate the Program specialist of the requirements for Individuals' physical examinations as per 6400.141(c)(1)-(15) and that no required areas shall be left blank and the agency procedures for obtaining missing information from the completing medical professions. Documentation of the training shall be kept. Immediately, upon completion and at least quarterly for 1 year, the CEO and the program specialist shall audit all individuals' current physical examination to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 8/29/18)] |
05/03/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 2/19/18 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. ''Repeated Violation-5/1/17, et al'' | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The CEO reviewed the current medical form for Individual #1 for physical examination completed 2/19/18. The CEO created a new form to address the continue missed medical infomation pertinent to diagnosis and treatment in case of an emergency. The CEO will train the PS on the newly created medical form. The CEO will review the document for compliance after Individual #1 next examination to ensure compliance.. [Immediately, the CEO shall educate the Program specialist of the requirements for Individuals' physical examinations as per 6400.141(c)(1)-(15) and that no required areas shall be left blank and the agency procedures for obtaining missing information from the completing medical professions. Documentation of the training shall be kept. Immediately, upon completion and at least quarterly for 1 year, the CEO and the program specialist shall audit all individuals' current physical examination to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 8/29/18)] |
05/03/2018
| Implemented |
| 6400.142(a) | Individual #1, date of birth 6/13/76, admitted 3/28/17, did not have a dental examination. ''Repeated Violation-5/1/17, et al'' | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The CEO reviewed the electronic files for Individual #1 finding a completed dental examination 2/26/18. The CEO updated the lodding process for all apointments for Individual #1 and trained the PS on the updated process. The CEO will review the new dnetal appointment logging process with the PS every 3 months to ensure continued compliance. [Documentation of aforementioned audits of the tracking system shall be kept. Individual #1 had a dental examination on 6/18/18. Immediately and upon completion of dental examinations, the CEO and Program specialist shall review all individuals dental examination documentation to ensure timely completion and health needs are provided. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
| 6400.181(f) | The program specialist did not provide the Individual #1's assessment dated 4/8/17 to the plan team members for the ISP annual meeting held 5/15/17. | (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).
| The CEO reviewed the assessment completed 4/8/17 and annual meeting held 5/15/17. The assessment for individual with service date 3/28/17 was completed by SC and agency PS the only plan team members at time of service. The CEO provided training to the PS on the requirements of 6400.181(f) and will review 30 calender days prior to an ISP meeting for development, annual updates and revisions. [Immediately, the CEO and program specialist shall develop and implement a tracking system to ensure all individuals' assessments are completed and provided to plan team members at least 30 days prior to the annual ISP meeting. Immediately, upon hire and at least annually, the CEO shall educate the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO shall audit all individuals' assessments and correspondence to the team documentation to ensure the program specialist has completed assessments timely and provided assessment to the plan team members at least 30 days prior to the ISP meetings
as required. Documentation of audits shall be kept.(DPOC by AES,HSLS on 8/30/18)] |
05/03/2018
| Implemented |
| 6400.186(a) | The program specialist did not complete an ISP review for Individual #1, date of admission 3/28/17 | 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. | The CEO reviewed the personal files for Individual #1 date of admission 3/28/17 finding the completed ISP review. The CEO updated the logging process for Individual #1 personal files and trained the PS on the new process. The CEO will review the new process with the PS every 3 months to ensure the continued compliance. [The program specialist completed ISP reviews for Individual #1 from January 2018 to July 2018. Immediately, upon hire and at least annually, the CEO shall educate the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO shall audit all individuals' ISP reviews to ensure the program specialist has completed ISP review for all individual as required. Documentation of audits shall be kept.(DPOC by AES,HSLS on 8/30/18)] |
05/03/2018
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not include emergency information for the individual including the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| The CEO reviewed the files of Individual #1 and spoke with Individual # 1 concerning emergency information listing agency as contact. The CEO trained the PS on the requirements of 6400.211(b)(1) and updated Individual #1 contact information with agency name, address, telephone number and relationship of agency as designated person contact. The CEO will review the contact information with PS and Individual #1 every 3 months to ensure continued compliance. [Immediately, the CEO shall educate the program specialist on the requirements of individuals' records as per 6400.211 to 218. Documentation of training shall be kept. Documentation of audits every 3 month by the CEO shall be kept. (DPOC by AES,HSLS on 8/17/18)] |
05/03/2018
| Implemented |
|
|
|
SIN-00113828
|
Renewal
|
05/01/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | There was not a signed and dated statement acknowledging receipt of the information on rights for Individual #1, date of admission 3/30/17. | 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. | No plan of correction required, Individual #1 initial admission date of 3/30/17. Individual #1 was 2 days out of surgery requiring total bed rest for a period of 14 days. Individual #1 was not able to sign and date the company orientation checklist until 4/20/17 due to individual #1 physical condition. Individual #1 was read their rights on 3/30/17 and later completed the check list 4/20/17 alleviating the non compliance. The CEO placed the signed acknowledgment receipt of rights in individua #1 binder. [Individual #1 sign a copy of "individual rights" on 7/10/17. Upon admission and annually the CEO shall inform individuals and others as appropriate of the information on rights and ensure the signed and dated statement are kept in each individual's record. Immediately, CEO shall develop and implement a tracking system to ensure that individuals' are informed of the information on rights, timely. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.111(a) | The fire extinguisher in the home had a 1-A 10 BC rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The CEO purchased new fire extinguishers with a minimum 2-A rating for each floor, incluing the basement and attic. The CEO reviewed the non compliance and the Program Specialist that trained the staff in their montlhy meeting. The Program Specialist completes a monthly checklist thats reviewed and signed by the CEO. [The CEO shall place a fire extinguisher with a minimum 2-A Rating in the community home. Immediately, the CEO shall train all staff persons and individuals of the location of each of the fire extinguisher. Documentation of training shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.113(a) | Individual #1, date of admission 3/30/17, was instructed in fire safety on 4/20/17. | 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. | No plan of correction required, individual #1, date of admission 3/30/17. Individual #1 arrived 2 days after surgery not being phyically unble to complete any fire safety training. Individual #1 was bedredden and unable to completed physically complete fire safety as documented in Individual medical records. The CEO direct the Program Specialist to complete the fire safety training 4/20/17 after individual #1 was physically able. The Program Specialist monitors the fire safety records daily and the CEO reviews monthly logging results in the montlhy binder. [Plan of correction is not acceptable. Upon admission and annually, all individuals shall be educated in fire safety as required. Immediately, the CEO shall develop and implement an admission checklist for individuals newly admitted into the home to include fire safety training to ensure timely completion of required trainings. Documentation of trainings shall be kept. Upon admission the CEO shall review the checklist and trainings to ensure timely completion. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.141(c)(6) | The physical examination, completed 4/27/17, for Individual #1 did not include a Tuberculin skin test by Mantoux method with negative results. | 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. | No plan of correction required, the phyiscal examination dated 2/16/17 shows negative results for Tuberculin skin testing by Mantoux method completed 7/21/16. The CEO verified the information and placed the physical evaluation in individual#1 file. The Program Specialist reviews and updates all records daily in the electronic documentation software Therap. [The CEO obtained a physical examination for Individual #1 completed 2/16/17 from Individual #1's previous residential provider. which includes a Tuberculin skin testing completed 7/21/16. Immediately, the CEO and program specialist shall review 6400.213(1)-(14) to ensure all individual records include the required information including current individual's physical examination. Immediately, the CEO shall develop and implement policies and procedures for record retention to ensure the Department has access to individual record including physical examinations upon request. Documentation of reviews and policies and procedures shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.141(c)(9) | The physical examination, completed 4/27/17 for Individual #1, date of birth 6/13/76 did not include a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | No plan of correction required, individual #1, date of birth 6/13/76 physical examination completed 2/16/17 show individual #1 declined prostate examination. The CEO directed the administration assistant to place the physical examination in Individual #1 binder and documented in the electronic software Therap. The Program Specialist and CEO reviews the recored data daily to alleviate any non compliance. [Individual #1 sign as refusing a prostate examination on 5/8/17. Immediately, the program specialist and CEO shall develop and implement a plan to train Individual #1 about the need for healthcare including a prostate examination for men 40 years of age or older and document in the individual's record as per 6400.143. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.141(c)(10) | The physical examination, completed 4/27/17, for Individual #1 did not address communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | No plan of correction required for individual #1, the CEO reviewed the physical examination dated 2/16/17 showing individual #1 has no communicable disease. Individual #1 has numerous visits to the doctors office due the physical limitations and numerous visit to complete all the required compliances for their physical. The 2/16/17 physical have been placed in Individual #1 binder and updated in the electronic documentation software to be reviewed by the Program Specialist and CEO daily.[The CEO obtained a physical examination for Individual #1 completed 2/16/17 from Individual #1's previous residential provider which addresses communicable disease. Immediately, the CEO and program specialist shall review 6400.213(1)-(14) to ensure all individual records include the required information including individual physical examination. Immediately, the CEO shall develop and implement policies and procedures for record retention to ensure the Department has access to individual record including physical examination upon request. Documentation of reviews and policies and procedures shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.141(c)(14) | The physical examination, completed 4/27/17, for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | No plan of correction required, phycial examination completed 02/16/17 shows individual #1 information pertinent to diagnosis and treatment in case of emergency. The CEO updated Individual #1 binder with the 02/16/17 physical exmination and log the information in the electronic documentation software to be reviewed monthly by the Program Specialist and CEO.[The CEO obtained a physical examination for Individual #1 completed 2/16/17 from Individual #1's previous residential provider which includes a medical information pertinent to diagnosis and treatment in case of an emergency completed 7/21/16. Immediately, the CEO and program specialist shall review 6400.213(1)-(14) to ensure all individual records include the required information including individual physical examination. Immediately, the CEO shall develop and implement policies and procedures for record retention to ensure the Department has access to individual record including physical examination upon request. Documentation of reviews and policies and procedures shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.141(c)(15) | The physical examination, completed 4/27/17, for Individual #1 did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | No plan of correction required, the physical examination completed 02/16/17 for individual #1 included special instructions for the individual's diet. The CEO updated Individual #1 binder with the 02/16/17 physical examination and recorded in the electronic documentation software to be reviewed daily by the Program Specialist and CEO to alleviate any non compliance. [The CEO obtained a physical examination for Individual #1 completed 2/16/17 from Individual #1's previous residential provider which includes special instructions for the individual's diet completed 7/21/16. Immediately, the CEO and program specialist shall review 6400.213(1)-(14) to ensure all individual records include the required information including individual physical examination. Immediately, the CEO shall develop and implement policies and procedures for record retention to ensure the Department has access to individual record including physical examination upon request. Documentation of reviews and policies and procedures shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.142(a) | Individual #1, date of birth 6/13/76, admitted 3/30/17, did not have a dental examination. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | No non compliance, Individual #1, date of birth 6/13/75, admitted 3/30/17 verified last dental appointment was April 29, 2016. The CEO verified with Steel City Dental the scheduled appointment made by individual #1 September 20th, 2017. [A financial record dated 4/29/16 from dental appointment for Individual #1 was available. CEO shall ensure Individual #1 attends scheduled dental examinations as required. Documentation of the dental examination shall be kept in Individual #1's record. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.142(f) | Individual #1, date of admission 3/30/17, did not 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. | No plan of correction required, written documentation shows individual #1 achieved dental hygiene independence. The CEO did updated individual records to include a written plan for dental hygiene. The CEO informed individual #1 of the denta hyiene plan created and individual #1 agreed to follow the plan. The staff monitors daily individual #1 progress and logs the results in the electronic documentation software. The Program Specialist and CEO reviews all records monthly. [On 7/7/17, CEO has educated Individual #1 of the written plan of dental hygiene and signed upon receipt. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.164(a) | Nystatin 100,000 Unit/GM Powder, apply to groin twice daily prescribed for Individual #1 was on the May 2017 medication administration record to be administered one application daily at bedtime. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The CEO reviewed the medication administration record of Individual #1 May 2017 record and updated the Nystatin 100,000 Unit/GM Powder to apply to groin twice daily. The CEO hired a trained Direct Service Worker that completed and passed the Department Medication Administration Course to review all medications after picking up from the pharmacy. The CEO will monitor the electronic record of all the medication label's monthly to alleviate non compliances. [Individual #1s MAR was updated with the correct dosage. Immediately and continuing at least weekly for 1 month and continuing at least monthly, CEO or a designated staff person who has completed the Department approved medication administration training shall review all individuals' doctors orders, medications and Medication administration records to ensure individuals' are being administered medication as prescribed and documented as required. Documentation of reviews shall be kept. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.168(d) | Program Specialist #1, Direct Service Worker #2, Direct Service Worker #3 have initialed Individual #'1 April 2017 Medication Administration Record throughout the month as administering medication to Individual #1. Program Specialist #1, Direct Service Worker #2, Direct Service Worker #3 have not completed and passed the Department's Medication Administration Course. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | The CEO immediatley stopped Program Specialist #1, Direct Service Worker #2, Direct Service Worker #3 from administering medication to Individual #1 April 2017 Medication Administration Record. The CEO directed all non compliance staff to completed and pass the Department's Medication Administration Course. The Program Specialist #1 and Diect Service Worker that have completed and passeed the Department's Medication Administration Course are the only staff administering medication to Individual #1. The Program Specialist #1 will complete the Train the Trainer course to train the company staff to alleviate any future non compliance. No staff will be allowed to administer medication without being training by one of the companies Train the Trainer staff completed and passed the Department's Medication Administration Course. The Program Specialist will review all staff training records monthly and CEO will sign off on the monthly report to alleviate non compliances. [Program Specialist/CEO #1 has passed the Department Medication Administration Course on 5/7/17 and has signed as administering all individuals' medications on June 2017 and July 2017 medication administration records. Direct Service Worker #2 and Direct Service Worker #3 are no longer employed at the agency. Prior to administered medication, CEO shall ensure all staff persons have completed and passed the medication administration course initially and annually. Documentation of all trainings shall be kept and available for review upon request from the Department. (AS 7/17/17)] |
06/19/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include hair color, identifying marks and 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. | The CEO updated Individual #1's record to show hair color, identiying marks and religious affilation. The company policy was updated and reviewed with management to alleviate the non compliance in the future. The CEO will review Individual #1 records monthly for any non compliance and review if any in the staff monthly meeting. [Individual #1's record was updated to include hair color, identifying marks and religious affiliation. Immediately and at least quarterly, the program specialist shall review all individuals' records to ensure all required personal information is included. Documentation of review shall be kept. (AS 7/17/27)] |
06/19/2017
| Implemented |
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SIN-00239357
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Renewal
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02/13/2024
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Compliant - Finalized
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SIN-00217168
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Unannounced Monitoring
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01/10/2023
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Compliant - Finalized
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SIN-00192930
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Unannounced Monitoring
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09/08/2021
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Compliant - Finalized
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SIN-00177122
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Unannounced Monitoring
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09/28/2020
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Compliant - Finalized
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