| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(g) | Individual #1 resides at a community home operated by Faithful Homes. staff #1, CEO of Faithful Homes, prohibited Individual #1 from receiving visitors until 5pm. Staff #1 corresponded with Individual #1's mother via a 2/19/19 email exchange which reads as follows: I very clearly told you that no visitors until 5pm but you arrived at 3 regardless. In addition, your arrival was unannounced, and we have asked multiple times that you please let us know you are coming. The email continues to read: at this point, you are not welcome into the home until boundaries are agreed upon. You have the option to remove your son permanently, but you do not have the option to enter the home. Staff #1 Prohibiting visitors access to the Individual #1's home constitutes a violation of Individual #1's rights to have unscheduled visitors of his choice. | An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. | 1. A plan to fix the immediate problem
a. Who: COO and CEO will allow access to individual #1 homes at any time announced or unannounced for all family members or any natural support persons listed in the ISP. This will continue as the practice at the other homes.
b. What will be corrected: Allow entry at all times to home (s) with no restrictions with individuals approval. Also allow access to Health Care Representatives and other family/natural support persons listed. If individual cannot confirm a desire for visitors it will be assumed that they do want the visitor to have access. This will be granted even unannounced regardless if the visitor has already agreed in writing that their understanding is that provider would prefer advance notice. See attached agreement of individual #1 family.
c. When and How: Granted 2/20/2019, which was the next day.
All house managers were retrained on this practice on 3/6/2019.
2. A plan to prevent future occurrences:
There will be no further restrictions to this home from provider. Additionally, all house managers were retrained on 3/6/2019. If there is the occurrence of intimidating behavior by visitor, SC and Regional ODP will be informed for further direction. Access to all other homes has never and will never be restricted.
If family decides to inform us of arrival, we will ask individual if this is his choice to have a visitor. If they do not, we will still allow them full access anytime.
A boundaries meeting was initially schedule for 2/22/2019 but then was rescheduled for 3/5/2019. Provider participated in a facilitation process on 3/5/2019. Participants included the central region ODP director, state selected facilitator, select provider staff, SC, and Individual number 1¿s family. SC has agreed to facilitate meetings with the provider and family on a monthly basis. Meeting minutes will be issued.
When signs of conflict are recognized between provider and family members the provider will reach out to the SC to setup a meeting with provider, family, coordination entities and mediator. This will ensure that conflict resolution occurs in a timely manner. ODP will be contacted when questions arise regarding interpretation of regulations
3. Training plan for staff:
Individuals #1¿s staff was trained on 2/20/2019. Other house managers were trained on 3/6/2019 utilizing training sign off sheet titled 6400.33 (g). House managers, Operations and SC will be retrained in recognizing signs of conflict by 4/15/2019.
4. Send documentation that will enable validation:
Training log 6400.33 (g) available for validation, A training log titled Recognizing signs of Conflict will be provided upon completion. |
04/15/2019
| Implemented |
| 6400.77(b) | No tweezers in the first aid kit at the time of the inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 1. A plan to fix the immediate problem
a. Who: House manager, operations manager and compliance officer
b. What will be corrected: First aid kits will be checked each month and documented on the licensing tool section physical site. Additionally, all first aid kits will be inspected by Operations Manager and Compliance Officer by 4/15/19.
c. When and How: The licensing tool physical site section will be completed monthly by the house manger effective 3/2019. Operations manager and compliance officer will review monthly for all homes.
2. A plan to prevent future occurrences:
The licensing tool physical site, will be completed by the house manager each month and reviewed by the operations manager and the compliance officer.
3. Training plan for staff:
Managers and admin team will be trained on this regulation by 3/31/2019 and a attendance sheet will be signed called 6400.77 (b)
4. Send documentation that will enable validation:
Training log 6400.77 (b) will be sent upon completion. |
03/31/2019
| Implemented |
| 6400.151(c)(3) | Staff #2 physical dated 8/30/18 did not include statement of communicable disease. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | 1. A plan to fix the immediate problem.
a. Who: Employee no longer works for provider. Compliance officer will review all other active employees by 3/8/2019. This will be reviewed COO by 3/15/2019.
b. What will be corrected: HR will review the physical to make sure that ¿Free from communicable diseases¿ is clearly documented on all new employee physicals.
Additionally, all employee physicals have been reviewed by the compliance officer.
c. New employees for all homes will be required to have the physical documented on our physical form or have their doctor complete a supplemental form that indicates that the employee is free from communicable disease.
2. A plan to prevent future occurrences:
New employees will be required to have the physical documented on our physical form or have their doctor complete a supplemental form that indicates that the employee is free from communicable disease. The employee files will be reviewed monthly for compliance of this items by the compliance officer and reviewed by the COO.
3. Training plan for staff:
Recruiter and compliance officer will be trained in this procedure by 3/31/19 and be reviewed and signed off by COO. Training sheet titled 6400.151 (c ) will be executed.
4. Send documentation that will enable validation:
Training log titled 6400.151 (c)(3)will be sent upon completion. |
03/31/2019
| Implemented |
| 6400.162(a) | Individual #'1's Senna lax 8.6mg did not have a medication label. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | 1. A plan to fix the immediate problem
a. Who: Agency learned at facilitation meeting on 3/5 that mother is the Health Care Representative for individual number 1. Agency has reviewed the 6400 with Mother several times. Additionally, central region has sent mother a full copy of the 6400 regulations. Mother has chosen to not fill this as a prescription.
All other houses and individuals will be audited by program specialist and operations manager to ensure that all medications have a label that match the doctor¿s orders.
b. What will be corrected: Agency will document mother¿s choice to obtain the medication OTC and refusal to allow agency to fill prescription with an attached label. Agency will not administer this medication since it does not have a pharmacy label.
For other houses and individuals, all labels will be on medications whether prescription or OTC.
c. When and how: Agency has created a communication log as of 3/4/2019 and will document Health Care Representative request to obtain the medication over the counter.
Other houses and individual medications will be audited by program specialist and operations manager to ensure that all medications have a label that match the doctors orders.
2. A plan to prevent future occurrences:
Any additions or changes to the doctors orders including delivery of any unlabeled medication will be documented in the communication log. Weekly provider will provide this information to SC and licensing for further instructions.
For other individuals and houses, monthly the MAR spreadsheet will be audited by house manager and reviewed by the program specialist.
3. Training plan for staff:
On 3/5/2019 a meeting occurred that included the central region ODP director, state selected facilitator and select provider staff, SC, and Individual number 1¿s family. Reviewed was the legal status and permissions that the Health Care Representative for individual number 1 family has. Meeting minutes are not yet available but it was clear that mother is the Health Care Representative and has legal authority to make decisions for Individual number 1 and provider cannot override her decision. It was also made clear and agreed that provider staff is to provide all facts and data to family to make their decisions without reservation. On 3/6/2019 provider held a information and training session with house managers, operations and other staff to review this decision. A sign off sheet titled 6400.162 (a) was completed.
This meeting was also used to refresh the other house managers on correct labeling of medications.
4. Send documentation that will enable validation:
A sign off sheet for 6400.162 (a) will be submitted. |
03/06/2019
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not contain height and Identifying marks. | 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.
| 1. A plan to fix the immediate problem
a. Who: Program specialist has added this information to individual 1¿s record and compliance officer has confirmed that it is in the record.
Each house manager, will review their home and the program specialist will verify that all information is correct.
b. What will be corrected: Face sheets will contain all information specified in this regulation 6400.231 (1) (i).
c. When and How: Individual 1¿s record was corrected by program specialist on 3/4/2019 and verified by compliance officer. All individual¿s face sheets will be revised if needed by House Manager and verified by Program Specialist
2. A plan to prevent future occurrences:
Upon intake the Executive director will ensure that all information is obtained and added to the individual¿s record prior to move in date and Compliance Officer will verify. Compliance officer will annually ensure photograph is reprehensive of individuals current appearance and will be reviewed by DOO.
3. Training plan for staff
House managers will be trained on this new procedure by 4/15/19 and verified by Operations Manager. A training sign off sheet will be completed for training of 6400.213 (1) (i).
4. Send documentation that will enable validation:
Training titled 6400.213 (1) (i) log will be submitted upon completion. |
04/15/2019
| Implemented |
| 6400.213(11) | Individual #1's ISP states seasonal allergies and the physical dated 12/14/18 does not list that. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | 1. A plan to fix the immediate problem
a. Who: House Manager sent physical to PCP to update individual 1¿s allergies. PCP will complete the physical by 4/1/19.
Each house manager, will review their home and the program specialist will verify that all content is consistent in ISP and physical.
b. What will be corrected: Physicals and ISPs will contain the same information in regards to allergies and diagnosis.
c. When and How: Program Specialist will contact physician to update paperwork or if physician does not agree to contact SC to remove from ISP by 4/15/19. All individual¿s physicals and ISPs will be reviewed for accuracy by Program Specialist and reviewed for accuracy by Compliance Officer by 4/15/19.
2. A plan to prevent future occurrences
On a monthly basis the house managers will update a spread sheet comparing ISP, Assessment, Face Sheet and Physicals. This will ensure that they all have consistent content. This spreadsheet will be reviewed and approved by the Program Specialist monthly.
3. Training plan for staff:
House managers will be trained on this new document content review spreadsheet by 4/15/19. Training reviewed by Compliance Officer. Training on 6400.213(11) will be available for review by 4/15/2019.
4. Send documentation that will enable validation:
Training log titled 6400.213 (11) will be submitted upon completion. |
04/15/2019
| Implemented |
| 6400.216(b) | On 2/15/19, Individual #1's mother visited the community home operated by Faithful Homes. Individual #1's mother requested access to Individual #l's medical records and was denied. | The individual, and the individual's parent, guardian or advocate, shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld. | 1. Plan to fix the immediate problem.
a. Who: Give family unrestricted access to individual 1¿s record and all individual records upon family request.
b. What will be corrected: Unrestricted access of all of individual 1¿s medical records and all individual¿s will be given to parent¿s upon request.
c. When and How: Unrestricted access to review the medical record was granted on 2/19/2019 to individual 1¿s parents. There were never restrictions for other individual records.
2. A plan to prevent future occurrences
As of 2/19/2019 Access to medical records is not restricted in any way to parents. Provider will report any changes, removal of medications or additions of medications to county and licensing for further instructions including OTC medications.
Provider will not interfere with Family adding or removing OTC medications. They will have free reign of individual 1¿s medications.
Provider will allow family to make copies of all medical records.
When signs of conflict are recognized between provider and family members the provider will reach out to the SC to setup a meeting with provider, family, coordination entities and mediator. This will ensure that conflict resolution occurs in a timely manner. ODP will be contacted when questions arise regarding interpretation of regulation
3.Training plan for staff:
Individual number 1¿s House manager and staff were trained also on 2/19/2019 regarding regulation 6400.216 b. All house managers and administrative team were trained on 3/6/19. And training log titled 6400.216 (b) was signed. The training was reviewed by COO). House managers, Operations and SC will be retrained in recognizing signs of conflict by 4/15/2019.
4. Send documentation that will enable validation
Training log titled 6400.216 (b) will be attached. A training log titled Recognizing signs of Conflict will be provided upon completion. |
04/15/2019
| Implemented |