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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #1 had a physical examination completed on 8/16/17 and then again on 2/27/19. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and without exception hereafter, all appointments will be logged and tracked in Therap, the agency¿s Electronic Medical Record System. The Program Manager will be responsible for scheduling all necessary appointments, including annual physicals, then entering them into in the Therap Appointment Scheduler system. The House Manager will be responsible for checking the Appointment Calendar daily and facilitating the appointments, which includes obtaining the required documentation and submitting that documentation to the Program Manager. The Program Manager is responsible for filing the documentation in the individual¿s chart, logging the details of the completed appointment in the Therap system and entering the date of the next appointment in the appointment calendar. On a monthly basis the Program Manager will run an ¿Appointment Report¿ from the Therap system to audit follow up, due appointments and compliance with respect to regulatory requirements. The Therap system will automatically time and date stamp each entry and report with the user¿s electronic signature making it possible to audit implementation without the addition of another layer of auditing or process. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring individuals' physical examination are completed timely with all required information of the aforementioned policies and procedures. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination completed on 2/27/19 did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | ACTION TO CORRECT VIOLATION: to address missing information from the 2-27-19 physical examination, allergies and other pertinent information gathered and added to the individual's record. Information was verified to be present as of 3-29-19. PLAN TO PREVENT REOCCURENCE: As of March 20, 2019, the agency¿s Annual Physical Exam form was updated to include an area for allergies and contraindicated medications. From this date forward the Program Manager will ensure not only that annual physical exams are both documented on the agency¿s Annual Physical Exam form and that each section of that form is completed in line with regulations.[Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all individuals' physical examinations are completed with all required information of the requirements as per 6400.141(c)(1)-(15) and the aforementioned review process. Documentation of the trainings shall be kept. Immediately and upon completion, a trained staff person shall audit all individuals' current physical examinations to ensure all required information is included and health services are arranged and provided. Documentation of audits shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 2/27/19 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. | ACTION TO CORRECT VIOLATION: to address missing information from the 2-27-19 physical examination, medical information pertinent to diagnosis and treatment in case of an emergency information gathered and added to the individual's record. Information was verified to be present as of 3-29-19. PLAN TO PREVENT REOCCURENCE: As of March 20, 2019, the agency¿s Annual Physical Exam form was updated to include an area for medical information pertinent to diagnosis and treatment in the case of emergency. From this date forward the Program Manger will ensure not only that annual physical exams are both documented on the agency¿s Annual Physical Exam form and that each section of that form is completed in line with regulations.[Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all individuals' physical examinations are completed with all required information of the requirements as per 6400.141(c)(1)-(15) and the aforementioned review process. Documentation of the trainings shall be kept. Immediately and upon completion, a trained staff person shall audit all individuals' current physical examinations to ensure all required information is included and health services are arranged and provided. Documentation of audits shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.142(a) | Individual #1, date of admission 8/22/17 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. | ACTION TO CORRECT VIOLATION: this individual's requires that dental examinations and care be done by a specialist while individual is under sedation, which requires preliminary bloodwork, guardian approval and a exam for medical clearance. Appointment scheduled for May 13, as it is the first available appointment and earliest possible date to complete the annual dental given pre-sedation requirements. PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and without exception hereafter, all appointments will be logged and tracked in Therap, the agency¿s Electronic Medical Record System. The Program Manager will be responsible for scheduling all necessary appointments, including annual dental appointments, then entering them into in the Therap Appointment Scheduler system. The House Manager will be responsible for checking the Appointment Calendar daily and facilitating the appointments, which includes obtaining the required documentation and submitting that documentation to the Program Manager. The Program Manager is responsible for filing the documentation in the individual¿s chart, logging the details of the completed appointment in the Therap system and entering the date of the next appointment in the appointment calendar. On a monthly basis the Program Manager will run an ¿Appointment Report¿ from the Therap system to audit follow up, due appointments and compliance with respect to regulatory requirements. The Therap system will automatically time and date stamp each entry and report with the user's electronic signature making it possible to audit implementation without the addition of another layer of auditing or process. In the future, should the individual's guardian refuse routine dental secondary to the added risk of sedation, or should the medical community determine that exams should not be conducted in line with regulations, this will be documented and kept on file [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all individuals' dental examinations are completed of the aforementioned process to ensure timely completion of all individuals' dental examinations. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.142(g) | Individual #1, date of admission 8/22/17 did not have a dental hygiene plan. | A dental hygiene plan shall be rewritten at least annually. | ACTION TO CORRECT VIOLATION: As of March 29, 2019, individual has a dated dental hygiene plan on record. PLAN TO PREVENT REOCCURENCE: Beginning March 28, 2018, the Program Manager will be required to update the individual¿s dental hygiene plan immediately following the annual dental appointment. The plan will: 1) reflect the dental hygiene recommendations for the individual, 2) be dated and 3) will be filed and maintained in the individual¿s record. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all individuals have a current dental hygiene plan of the aforementioned process to ensure timely completion of all individuals' dental hygiene plans. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/28/2019
| Implemented |
| 6400.163(c) | Individual #1 had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness completed on 3/2/18 and then again on 3/12/19. | 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. | ACTION TO CORRECT VIOLATION: there is a documented review for this individual on 3-12-19 and an appointment scheduled for 6-12-19. PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and without exception hereafter, all appointments will be logged and tracked in Therap, the agency¿s Electronic Medical Record System. The Program Manager will be responsible for scheduling all necessary appointments, including 3 month physician reviews for individuals taking medications to treat maladaptive behaviors, then entering them into in the Therap Appointment Scheduler system. The House Manager will be responsible for checking the Appointment Calendar daily and facilitating the appointments, which includes obtaining the required documentation and submitting that documentation to the Program Manager. The Program Manager is responsible for filing the documentation in the individual¿s chart, logging the details of the completed appointment in the Therap system and entering the date of the next appointment in the appointment calendar. On a monthly basis the Program Manager will run an ¿Appointment Report¿ from the Therap system to audit follow up, due appointments and compliance with respect to regulatory requirements. The Therap system will automatically time and date stamp each entry and report with the user¿s electronic signature making it possible to audit implementation without the addition of another layer of auditing or process. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring individuals have a psychiatric medication reviews completed timely of the aforementioned process to ensure timely completion of individuals' psychiatric medication reviews. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.164(b) | Trazadone, 100mg; Risperidone, 3mg; Melatonin, 5mg and Clonazepam, 1mg prescribed to Individual #1 were not logged as administered at 8:00PM on 3/13/19. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | ACTION TO CORRECT VIOLATION: To correct the absence of documentation of medications administered on 3-13-19, Program Manager first verified that medications were, in fact, administered as ordered. Following this, the administration of 8:00 medications was documented along with a notation of the late entry. Verification that steps were completed as described made on 3-29-19. PLAN TO PREVENT REOCCURENCE:Beginning March 28, 2019 House Managers will use the reporting and notification functions of the Therap system¿s eMAR module to identify any medication that is not immediately logged upon administration. (Note: Therap is the name of the agency¿s Electronic Medical Record system). Therap is equipped with a ¿Due Medication¿ report that identifies medications that have not been logged as of their designated administration time. House managers will be responsible for checking this notification and ensuring immediate documentation of administered medication. On a monthly basis, the Program Manager will be responsible for running a Medication Administration Record Report, evaluating medication documentation data and responding to any instances where failure to log immediately was not prevented by the Due Medication notification action steps. [Immediately, the CEO or designee shall educate all staff persons responsible for administering and review medications administration and documentation and aforementioned audits of the aforementioned process to ensure all individuals' medications are administered as prescribed and documented as required. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/14/2019
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment completed on 8/20/18, did not include the individual's progress over the last 365 calendar days and current level in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | PLAN TO PREVENT REOCCURENCE: As of March 20, 2019, the agency¿s Annual Assessment form was updated to include an area to assess and document progress over the last 365 calendar days and current level of functioning and skill for managing personal property. From this date forward the Program Manger will ensure not only that the annual assessment is completed on the agency¿s Assessment form, but also that each section of that form is completed in line with regulations. [Immediately, the CEO or designee shall educate the Program Specialist of the requirements of individuals' assessments as per 6400.181e (1)-(14). Documentation of the training shall be kept. Within 30 days of receipt of the plan of correction, the program specialist shall audit all individuals' current assessment to ensure all required information is completed as required. Documentation of the audits shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of individuals' current assessment to ensure the program specialist has completed and implemented all required information for individuals assessments. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment completed on 8/20/18 did not include the individual's progress over the last 365 calendar days and current level in community-integration. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | PLAN TO PREVENT REOCCURENCE: As of March 20, 2019, the agency¿s Annual Assessment form was updated to include an area to assess and document progress over the last 365 calendar days and current level of functioning and participation in community integration. From this date forward the Program Manger will ensure not only that the annual assessment is completed on the agency¿s Assessment form, but also that each section of that form is completed in line with regulations.[Immediately, the CEO or designee shall educate the Program Specialist of the requirements of individuals' assessments as per 6400.181e (1)-(14). Documentation of the training shall be kept. Within 30 days of receipt of the plan of correction, the program specialist shall audit all individuals' current assessment to ensure all required information is completed as required. Documentation of the audits shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of individuals' current assessment to ensure the program specialist has completed and implemented all required information for individuals assessments. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.186(b) | Individual #1 did not sign the ISP reviews for review periods from 1/1/18 to 3/31/18, from 4/1/18 to 6/30/18, from 7/1/18 to 9/30/18 and from 10/1/18 to 12/31/18. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | ACTION TO CORRECT VIOLATION: ISP reviews for the time period of 1/1/18 through 12/31/18 were reviewed with this individual. Verification that the individual signed as evidence of this review was completed 3-29-19. PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019, the agency will implement the following operational processes: By the 10th of April, July, October and January of each year the Program Manager will generate both a Quarterly ISP Data Programmatic report and a Quarterly Health Care Report from the Therap Electronic Medical Record system for the previous quarter (January- March, April- June, July- September, and October- December). The comprehensive report will include all of the information and components required by regulations and will be electronically signed and date stamped by the Program Manager. By the 14th of April, July, October and January the Program manager will review the reports with the individual, who will be given an opportunity to provide input before signing to verify that this review took place. By the 15th of April, July, October and January the Program Manager will draft and send the 90- day review along with the quarterly letter and declination notification to all applicable team members. By the last day of the month in April, July, October and January the Chief Operations Officer will run a report in Therap to verify and ensure that 90- day reviews are being completed as described[Within 30 days of receipt of the plan of correction, the CEO or designee shall educate the program specialist in the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and the agencies policies and procedures to ensure completion and review. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/20/2019
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include a 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.
| ACTION TO CORRECT VIOLATION: To correct the absence of information in this individuals record, religious affiliation was added on 3/13/19. PLAN TO PREVENT REOCCURENCE: Upon admission, the Program Manager will create a record in Therap, which is the agency¿s Electronic Health Record System, and will enter all identifying and demographic information, including ¿religious affiliation.¿ Prior to the date of admission, the Chief Operations Officer (or designee) will run an ¿Individual Data Form¿ report in the Therap system to audit and ensure that all required fields have been entered into the individual¿s record. Annually thereafter the Program manager will audit the record via the Individual Data Form and make any additions or corrections to the individual¿s record. The Therap system will automatically time and date stamp each entry, review and update made to the record along with each user¿s electronic signature so that verification of implementation can be monitored. [Immediately, the CEO or designee shall educate all staff person responsible for ensuring all individuals' personal information is included in the individual's record of the requirements as per 6400.213.1(I)-(vi) and the aforementioned completion and auditing procedures. Documentation of the training shall be kept. (SPOC by AES,HSLS on 4/24/19)] |
03/13/2019
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | The home did not provide orientation for Direct Service Worker #1, date of hire 9/2/17. The home did not provide orientation for Program Specialist #2, date of hire 2/2/18. | 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 #1 had orientation on 4/11/18. Program Specialist #2 had orientation completed 3/30/18. 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 9/2/17, did not have training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation. Program Specialist #2, date of hire 2/2/18, 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 #1 had training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation on 4/10/18. Program Specialist #2 had training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation on 3/5/18. 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 9/2/17, did not have fire safety training before working with individuals. Program Specialist #2, date of hire 2/2/18, 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 to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this training in first aid techniques 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 #1 had fire safety training on 4/11/18. Program Specialist #2 had fire safety training on 3/26/18. 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)] |
04/05/2018
| Implemented |
| 6400.46(i) | Direct Service Worker #1, date of hire 9/2/17, did not have training in first aid and Heimlich techniques. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The plan of correction for this issue of non-compliance is for Direct Service Worker # 1 to complete first aid and Heimlich technique training on 4.19.2018.The plan to address this issue of non-compliance is that Direct-Service Worker # 1 will complete this orientation training in the areas of intellectual disabilities, the principles of normalization, individual rights, and program planning and implementation by 4.13.2018. The orientation training in the areas of intellectual disabilities, the principles of normalization, individual rights, and program planning and implementation for the Program Specialist was completed on 3.23.2018.
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. [Not acceptable, plan of correction does not address violation. Direct Service Worker #1 had first aid training on 7/31/17. 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 within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Documentation of audits shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.110(a) | The home did not have a smoke detector in the attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The plan to address this issue of non-compliance is to have a smoke detector placed in the attic. This was placed in the attic on 3.23.2018 by ABC Fire Extinguisher.The plan to alleviate this violation moving forward is that AMA has an agreement with ABC Fire Extinguisher to check and replace all fire extinguishers in the homes annually or when needed. [On 4/18/18, an operable smoke detector was present in the attic of the home. Immediately, upon opening a home and continuing at least monthly, the CEO or designee shall check all homes to ensure all homes have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of the checks shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.111(a) | There was not a fire extinguisher located in the attic which contained stored items. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The plan to address this issue of non-compliance is to secure a fire extinguisher in the attic. This was completed by ABC Fire Extinguishers on 3.23.2018. The plan to alleviate this violation moving forward is that AMA has an agreement with ABC Fire Extinguisher to check and replace all fire extinguishers in the homes annually or when needed. [On 4/18/18, a fire extinguisher was present in the attic of the home. Immediately, upon opening a home and continuing at least monthly, the CEO or designee shall check all homes to ensure all homes have at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Documentation of the checks shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.112(d) | The fire drill held 12/14/17 had an evacuation time of 3 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | the plan to address this issue of non-compliance is a fire drill was conducted on 1.20.2018 and all individuals were evacuated safely within 2 minutes. The plan to alleviate this violation moving forward is the implementation of a Fire Drill Process. This Fire Drill Process begins with Fire safety Training in the New Hire Orientation Training Class, the annual fire safety training thereafter and the review of monthly fire drills by the Program Specialist. [Within 30 days of receipt of the plan of correction, the CEO or designee shall education all staff persons responsible for conducting fire drills on the requirements of conducting and documenting fire drills as per 6400.112(a)-(I). Documentation of the trainings shall be kept. Documentation of the aforementioned audits of fire drill records shall be kept. If fire drills are not conducted and documented as required, the CEO or Program specialist shall observe a fire drill at the home and address as needed to ensure all fire drills are conducted and documented as required. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.112(e) | There were no fire drills held during sleeping hours for the fire drill held between 8/22/17 and 2/6/18. | A fire drill shall be held during sleeping hours at least every 6 months. | The plan to alleviate this violation moving forward is the implementation of the Fire Drill process. This Fire Drill Process begins with Fire safety Training in the New Hire Orientation Training Class, the annual fire safety training thereafter and the review of monthly fire drills by the Program Specialist. [A fire drill was held during sleeping hours on 4/25/18. Within 30 days of receipt of the plan of correction, the CEO or designee shall education all staff persons responsible for conducting fire drills on the requirements of conducting and documenting fire drills as per 6400.112(a)-(I). Documentation of the trainings shall be kept. Documentation of the aforementioned audits of fire drill records shall be kept. If fire drills are not conducted and documented as required, the CEO or Program specialist shall observe a fire drill at the home and address as needed to ensure all fire drills are conducted and documented as required. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.151(a) | Program Specialist #2, date of hire 2/2/18, had a physical examination completed 2/9/18. | 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. | The plan to alleviate this violation in the future is the implementation of the New Hire/On boarding process implemented here at AMA. This process is managed by the HR manager who completes an initial screening of all potential applicants, completes a telephone pre-screening, schedules an interview and if the applicant is selected as an AMA employee, an offer letter with instructions on completing a Physical/TB and the required Physical form is provided to the potential AMA employee. Prior to being scheduled for New Hire orientation, the potential staff must provide a copy of the Physical with a TB test that has been read to the HR Manager. Once this is secured, the potential employee is scheduled for New Hire Orientation Training Class. [Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' records to ensure all 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. Documentation of audits shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
| 6400.151(c)(2) | Program Specialist #2, date of hire 2/2/18, had tuberculin skin testing completed 2/9/18. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The plan to alleviate this violation in the future is the implementation of the New Hire/On boarding process implemented here at AMA. This process is managed by the HR manager who completes an initial screening of all potential applicants, completes a telephone pre-screening, schedules an interview and if the applicant is selected as an AMA employee, an offer letter with instructions on completing a Physical/TB and the required Physical form is provided to the potential AMA employee. Prior to being scheduled for New Hire orientation, the potential staff must provide a copy of the Physical with a TB test that has been read by a registered nurse or a licensed practical nurse, licensed physician, licensed physician's assistant or a certified nurse practioner to the HR Manager. Once this is secured, the potential employee is scheduled for New Hire Orientation Training Class. [Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' records to ensure all 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 including Tuberculin testing within 12 months prior to employment and every 2 years thereafter. Documentation of audits shall be kept. (AS 5/1/18)] |
04/03/2018
| Implemented |
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