| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Receipts for Individual #3 indicate that basic personal care items that are to be supplied by the provider were purchase on 11/5/22. Items purchased were Suave hair 2n1 and Ivory bar soap. Basic personal care items are included in room and board. | Individual funds and property shall be used for the individual's benefit. | On 2/17/2023, all staff including management were trained on the importance of ensuring that Indvidual funds and property shall be used for the individuals benefit. Groceries and household items are purchased weekly and on weekly basis staff will include individual #3 ( higher functioning) with the shopping and they can add items needed for basic personal care and other needs. |
02/17/2023
| Implemented |
| 6400.68(b) | The hot water temperature in the first hallway bathroom was 122.9°F at time of inspection. Hot water shall not exceed 120°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | the hot water temperature was adjusted on 2/10/2023 and tested and documented to reflect compliance- this was also checked by the director and coordinator. all staff on 2/17/2023 were trained on the importance of checking to ensure safety and compliance as it pertains to Hot water temperatures in bathtubs and showers may not exceed 120°F. Staff on 2/17/2023 were walked thru the steps of how to test the hot water and the importance of varying the hot water sources that are tested. |
02/17/2023
| Implemented |
| 6400.82(d) | At the time of inspection, the pocket door on the hallway bathroom was stuck inside the wall and not able to be engaged and shut to ensure privacy. There was no substitution, such as a curtain, in place to ensure privacy. A second bathroom was available for use in the home that had a working door. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | On 2/17/2023 -the staff were retrained on the importance of privacy which shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. the door was fixed on 2/14/2023. |
02/17/2023
| Implemented |
| 6400.181(a) | Individual #3 was admitted into the program on 1/27/22. An initial assessment was completed by the admitting provider on 2/25/22. The financial assessment in the document was inadequate to describe the level of assistance required. The 2/25/22 assessment states that "Stephen needs help managing his money." The "Financial Independence" section of the 2/25/22 assessment marks all areas as "N/A." Written description in the section notes that "finances are managed by his Repayee. Does not currently have a job, but has expressed an interest. No progress in this area."
The 2023 assessment for Individual #3 completed on 2/3/23 states under the "Financial Independence" heading and "Maintain funds safely" section "prompts" without further description. Progress for this section is noted as "has a bank card where he receives his paycheck. Staff need to encourage to keep his receipts."
The 2023 assessment for Individual #3 notes in the "Financial Independence" heading and "maintain/use bank account" section "Total" without further description. Progress in this section is noted as "The Advocacy Alliance is rep payee for (Individual #3)."
Neither the 2022 nor the 2023 assessments for Individual #3 adequately described the level of assistance needed by Individual #3 to make purchases, use a debit card or handle money.
The 2023 assessment for Individual #3 does not include progress or lack thereof for all sections where notation of progress is required. The Health, Motor and Communication skills, Activities of residential living, Personal Adjustment, Socialization, Recreation, Financial Independence, Managing Personal Property and Community Integration sections include limited general statements of ability rather than an assessment of skills and progress noted over the previous year.
The assessment cannot be vague or nonspecific.
Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful.
Assessments that lack quality i.e. are not individualized, personalized, relevant to the person's age and do not address the specific needs of the person, will lead to services that lack quality; services that lack quality lead to harm. | 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. | On 2/17/2023 -All staff were trained on the importance of having a up to date assessment within the home and that 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. On 2/17/2023 the director /program specialist was also retrained on the level of detail and specific needed within the assessment and a refresher training was completed on the program that is used to create the assessment. HIs assessment will be updated by 3/3/2023 to reflect the necessary updates regarding the level of assistance needed for his finances, financial independence as it pertains to making purchases, it was also updated to be less vague and more specific and have more quality regarding his communication skills, health, etc. and overall progress. |
03/03/2023
| Implemented |
| 6400.32(r)(4) | The bedroom doors in the home had coin key locks. Coin key locks do not allow for easy and immediate access. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | the door locks were changed on 2/14/2023 and the coin key locks replaced.
all staff on 2/17/2023 were trained on the importance of ensuring that the locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. |
02/17/2023
| Implemented |
| 6400.44(b)(1) | The 2023 assessment for Individual #3 was completed by Staff #6 as indicated on the last page of the assessment by "Author: Staff #6." Staff #6 does not meet the qualifications for a Program Specialist and holds the title of Program Coordinator. The Director of the program, Staff#4 indicated at the time of inspection that the plan was written by Staff #6 but signed off on by Staff #4. The February 2020 6400 Regulatory Compliance Guide states that "Completing high-quality, accurate assessments is one of the most important duties of the program specialist." Assessments shall be coordinated and completed by a qualified Program Specialist. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | The management staff were trained on the importance of making sure that only the program specialist shall be responsible for the following: Coordinating the completion of assessments. the management staff and program specialist were also trained on the importance of using the kaliedacare system which is the program that is used to create the assessments. The glitch in the online Kaleidacare system was fixed and the assessments author will be updated by 3/3/3023 |
03/03/2023
| Implemented |