| 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 2/28/18. The expiration of the agency's certification of compliance is 4/4/2018. | 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 plan to address this issue of non-compliance is the a self-assessment of the home was completed on 2.28.18. This date was past the 3-6 months required timeline. The plan to alleviate this violation moving forward is the implementation of a Service Development Process at AMA. This process will provide oversight for the timely completion of all self-assessments for homes currently licensed within the 3-6 month window prior to the expiration of AMA's Certificate of Compliance which is 4.4.2019. This process is the responsibility of the Program Director. [Prior to 3 months of the expiration of the agency's certificate of compliance, the CEO or designated management staff person shall audit all self-assessments to ensure accurate and timely completion. Documentation of the audits shall be kept. (AS 5/1/18)] |
04/06/2018
| Implemented |
| 6400.31(b) | Individual #1, date of admission 11/29/17, did not sign and date acknowledging receipt of the information on rights upon admission. | 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. | The plan to address this issue of non-compliance is to have individual #1 sign and date the information for Individual's Rights. This was completed on 4.6.2018.
The plan to alleviate this violation moving forward is that AMA has implemented an Admission Process that utilizes a Transition plan to review all individuals referred for services at AMA In the Transition Plan, On Move in Day , the Program Specialist will Review the Statement of Individual Rights with the individual and or the individual's parent, guardian or advocate and have them sign this form. This review will occur annually thereafter. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are informed of individual right, timely and signed statements are kept. Immediately, upon admission and quarterly for 1 year, the CEO or designated management staff person shall audit all individuals statements acknowledge receipt of information of rights and the aforementioned tracking system to ensure all individuals are informed of individual rights timely and statement acknowledging receipt is kept. Documentation of audits shall be kept. (AS 5/1/18)] |
04/06/2018
| Implemented |
| 6400.44(b)(10) | The program specialist did not review, sign, and date the monthly documentation for Individual #1, date of admission 11/29/17. | 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 plan to address this issue of non-compliance is that ISP Goal Data documentation has been implemented on 2.26.2018. With this in place, a monthly review will be generated on 4.9.2018. This ISP review will be provided to all member's of individual #1's team. The plan to alleviate this violation in the future is that AMA Support Serrvices has implemented a Monthly Review Process The Program Specialist is responsible for the monitoring and completion of this process. This process is, the Program Specialist will generate monthly documentation of an individual's participation and progress toward outcomes. [Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist of the responsibilities of program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall review all individuals' monthly documentation to ensure the program specialist reviews, signs and dates all individuals' monthly documentation of an individual's participation and progress toward outcomes as required. Documentation of audits shall be kept. (AS 5/1/18)] |
04/09/2018
| Implemented |
| 6400.46(a) | The home did not provide orientation for Direct Service Worker #1, date of hire 9/26/17. The home did not provide orientation for Direct Service Worker #2, date of hire 10/31/17. | 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 plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this orientation training on 4.5.2018.The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #2 is no longer employed at the agency. Immediately and upon hire, the CEO or designee shall audit all staff persons' orientations to ensure all staff persons have orientation 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. Documentation of audits shall be kept. (AS 5/1/18)] |
04/05/2018
| Implemented |
| 6400.46(e) | Direct Service Worker #1, date of hire 9/26/17, 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 10/31/17, 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 plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this orientation training on 4.5.2018. The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #2 is no longer employed at the agency. Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons 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. Documentation of audits shall be kept. (AS 5/1/18)] |
04/05/2018
| Implemented |
| 6400.46(f) | Direct Service Worker #1, date of hire 9/26/17, did not have fire safety training before working with individuals. Direct Service Worker #2, date of hire 10/31/17, did not have fire safety training before working with individuals. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The Plan of Correction for fire safety training for Direct Service Worker, # 1, hire date of 9.26.2017 will be completed by 4.20.2018. The Direct Service Worker # 2, hire date 10.31.2017 has been terminated.
The plan to alleviate this violation moving forward is that AMA Support Services has implemented a New Hire/Orientation Training Process. This is a week-long new hire training for all newly hired staff. This training must be completed prior to any staff being assigned a shift within any AMA home. [Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons are trained 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. . Documentation of audits shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.46(h) | Direct Service Worker #2, date of hire 10/31/17, did not have training in first aid techniques before working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | The plan to address this issue of non-compliance for Direct Service Worker # 2 is termination. This occurred on 3.30.2018. The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month.
AMA has hired a Certified 1st Aid/CPR trainer to facilitate this training during the New Hire Orientation Training Program.[Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons are trained in training in first aid techniques before working with individuals. Documentation of audits shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.110(c) | There was not a smoke detector in the common area or hallway within 15 feet of the bedrooms located to the left and the right of the hallway on the main floor of the home. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | The plan to address this issue of non-compliance is to place an operable smoke detector in the hallway within 15 feet of the bedrooms located to the left and the right of the hallway on the main floor of the home. This smoke detector was replaced on 3.20.2018. The plan to alleviate this violation moving forward is the implementation of a monthly site audit checklist. This is an environmental and safety audit checklist comprised of the 6400 regulations pertaining to physical site and safety requirements. This site audit checklist is completed monthly by the House Manager and submitted to the Program Specialist by the 5th of each month. [Prior to completing the site checklist, the CEO or designee shall train the house managers on the requirements of the regulations pertaining to the checklist. Documentation of the training shall be kept. Documentation of the audits of the site checklist by the Program Specialist shall be kept. (AS 5/1/18)] |
05/01/2018
| Implemented |
| 6400.113(a) | Individual #1, date of admission 11/29/17, did not have fire safety training. | 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. | The plan of correction to address this issue of non-compliance is that individual # 1 will complete fire safety training on 4.9.2018. The plan to alleviate this violation moving forward is the implementation of the Admission process here at AMA. As outlined in the Admission Process, on the day of admission at AMA all individuals will complete emergency training. From this admission date, Individual Emergency Training will be completed annually.
The Program Specialist will be responsible for the completion of this initial and annual Individual Emergency Training.[Immediately and continuing quarterly for 1 year, the CEO or designee shall audit all individuals' fire safety training to ensure all individual are 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, timely. (AS 5/1/18)] |
04/09/2018
| Implemented |
| 6400.163(c) | Individual #1, date of admission 11/29/17, is prescribed Risperidone 0.5 mg for mood disorder, and did not have a review of psychiatric medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The plan to address this issue of non-compliance is contacting the psychiatrists office to request the Medication Review documentation from the 1.11.2018 med review appointment for individual #1. This request was made on 4.4.2018.In the request made for information from 1.11.2018 med review appointment, AMA requested that the following information also be provided in the documentation: the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The plan to alleviate this violation moving forward is the implementation of the Medical Appointment Process. This process will be the responsibility of the Program Specialist. This process will be : all medical appointments will be entered in Therap-the web-based electronic record and documentation system utilized by AMA. All medical appointments will be entered for each individual in the Health section in Therap. Once entered, the appointments populate on the Therap Appointment Calendar. Reminders for all up and coming appointments are provided through the Therap system. In addition to tracking all medical appointments, a medical consultation form is generated with space provided for the licensed physician to document : the reason for prescribing the medication, the need to continue the medication and the necessary dosage. [Immediately and upon completion, the CEO or designee who is certified to administer medication and educated in the requirements of psychiatric medication reviews as per 6400.163(c) shall audit all individuals' psychiatric medication reviews to ensure timely completion and that all required information is included and individuals are administered medications as prescribed. Documentation of audits shall be kept. (AS 5/1/18)] |
05/01/2018
| Implemented |
| 6400.167(a) | Direct Service Worker #1 who is not certified to administer medications, administered medications to Individual #1 on 3/2/18, 3/6/18, 3/7/18, 3/9/18, 3/13/18, 3/14/18, 3/16/18, 3/20/18 at 7:00 AM. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. | the plan to address this issue of non-compliance is that the Direct Service Worker # 1 will complete the required medication training. The plan on how this violation will be alleviated moving forward is the implementation of the Medication Administration Training program at AMA. This training is a part of the week-long new-hire orientation program that has been implemented at AMA along with the hiring of a Certified Medication Administration Trainer. The new hire-orientation program will occur during the 1st and 3rd week of each month. [Direct Service Worker #1 completed medication training on 4/6/18. Immediately, prior to administering medications and at least quarterly for 1 year, the CEO or designee shall audit all staff persons documentation of certification to administer medications to ensure only staff persons who are certified to administer medications are administering medication. Those who are not certified and/or do not have all required documentation shall immediately cease administering medication. Documentation of all audits shall be kept. (AS 5/1/18)] |
04/06/2018
| Implemented |
| 6400.181(e)(1) | The assessment dated 12/29/17 for Individual #1 did not include functional strengths, needs and preferences of the individual. This section was blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The plan to address this issue of non-compliance is that the Program Specialist has updated individual # 1's assessment to include functional strengths, needs and preferences of the individual. This was completed on 3.22.2018. The plan to alleviate this violation moving forward is the implementation of an Assessment Process at AMA. This process is : the Program Specialist will complete the Initial Functional Assessment within 60 days of admission and annually thereafter. [Within 15 days of receipt of the plan of correction the CEO or designee shall educate the program specialist of the information that must be included in individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and within 5 days of completion for 1 year, the CEO or designee shall audit all individuals' assessments to ensure the program specialist completed all individuals' assessments with all required information. Documentation of the audits shall be kept. (AS 5/1/18)] |
03/22/2018
| Implemented |
| 6400.181(e)(2) | The assessment dated 12/29/17 for Individual #1 did not include likes, dislikes and interest of the individual. This section was blank. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The plan to address this issue of non-compliance is that the Program Specialist has updated individual # 1's assessment to include the likes, dislikes and interests of the individual. This was completed on 3.22.2018.
The plan to alleviate this violation moving forward is the implementation of an Assessment Process at AMA. This process is : the Program Specialist will complete the Initial Functional Assessment within 60 days of admission and annually thereafter. [Within 15 days of receipt of the plan of correction the CEO or designee shall educate the program specialist of the information that must be included in individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and within 5 days of completion for 1 year, the CEO or designee shall audit all individuals' assessments to ensure the program specialist completed all individuals' assessments with all required information. Documentation of the audits shall be kept. (AS 5/1/18)] |
03/22/2018
| Implemented |
| 6400.186(a) | The program specialist did not complete an ISP review for Individual #1, date of admission 11/29/17. | 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 plan to address this issue of non-compliance is that ISP Goal Data documentation has been implemented on 2.26.2018. With this in place, a 3-month review will be generated on 5.26.2018. This ISP review will be provided to all member's of individual #1's team. This report will be generated on 5.26.2018.
The plan to alleviate this violation in the future is that AMA has implemented a Quarterly Review Process The Program Specialist is responsible for the monitoring and completion of this process.
This process is, the Program Specialist will generate a 3-month, ISP review report from the ISP data that has been entered in Therap, the web-based recording and documentation system in use by AMA. The Program Specialist will provide the ISP review report will be provided to all members on the individuals team. [Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist of the responsibilities of program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all individuals' ISP reviews to ensure the program specialist has completed ISP reviews 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. Documentation of audits shall be kept. (AS 5/1/18)] |
02/26/2018
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks and there was not a date on the photograph. | 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 plan to address this issue of non-compliance is that the identifying marks missing from Individual # 1's record has been revised to include all identifying mark information. A date on Individual # 1's photo has been placed on the back of this photo.The plan on how this violation will be alleviated moving forward is-AMA has implemented the use of an electronic record system, Therap. Therap is a web-based service that provides an integrated system for documentation, reporting and communication. AMA has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, entering the individual's personal information in the Individual Data form in Therap is an identified step to be completed in this Transition Plan. In Section 4 of the Transition Plan: On Move in Day-taking a picture and uploading this photo into Therap on the Individual data form is an identified step in this Transition Plan.
The Admission Process and completion of the Transition Plan is the responsibility of the Program Specialist.
The Admission Process is supported in AMA's Policy and Procedure Manual; Section F: Program Record Keeping-F1: Individual Records-Procedure-Each record will include-Personal information including : name, sex, admission date, birthdate, social security #, race, height, weight, color of hair, color of eyes and identifying marks. Language and the means of communication spoken or understood by the individual and the primary language used in the individual's home, if other than English. Religious affiliation, next of kin and a current dated photograph. [Immediately and continuing at least quarterly for 1 year, the CEO or designee educated in the required information in individuals' records as per 6400.213(1)-(14) shall audit all individuals' records to ensure all required information as per 6400.213(1)-(14) is included. Documentation of audits shall be kept. (AS 5/1/18)] |
03/22/2018
| Implemented |