|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | The window behind the bed in Individual #1's bedroom did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | ACTION TO CORRECT VIOLATION: screen placed in window and secured at the time of inspection. PLAN TO PREVENT REOCCURENCE: To ensure that all homes remain compliant with respect to physical site regulations the following actions will occur: Beginning March 20, 2019 and on a monthly basis thereafter, each house manager will complete a Physical Site audit. The Physical Site audit is based on the LII and captures level of compliance for each physical site licensing requirement. The House Manager will correct any minor areas of noncompliance at the time of inspection, will document items that need to be referred to maintenance personnel, and will submit the Site audit to his or her respective Program Manager. The Program Manager will review the site audit and will complete a maintenance request, submitting it to the COO. The COO will direct the actions of the handyman or secure a vendor to make the necessary repairs. Upon completion, the Program Manager will review the work for completion and verify, using the site audit in the subsequent month, that the issue is resolved. Should an emergency physical site issue arise, one that makes the home either unsafe or unlivable, the COO will be notified directly and if the issue or repair cannot be addressed immediately, the participant(s) will be relocated according to the individual¿s ISP and company policies and procedures. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate staff responsible for aforementioned process of their responsibilities to ensure the physical site of all community homes is maintained and not hazardous including windows, including windows in doors, shall be securely screened. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/15/2019
| Implemented |
| 6400.73(a) | The wooden hand rail along the three cement outside steps leading from the drive way to the front yard was loose and separating from the cement steps. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | ACTION TO CORRECT VIOLATION: handrail was fixed and secured on March 15, 2019. PLAN TO PREVENT REOCCURENCE: To ensure that all homes remain compliant with respect to physical site regulations the following actions will occur: Beginning March 20, 2019 and on a monthly basis thereafter, each house manager will complete a Physical Site audit. The Physical Site audit is based on the LII and captures level of compliance for each physical site licensing requirement. The House Manager will correct any minor areas of noncompliance at the time of inspection, will document items that need to be referred to maintenance personnel, and will submit the Site audit to his or her respective Program Manager. The Program Manager will review the site audit and will complete a maintenance request, submitting it to the COO. The COO will direct the actions of the handyman or secure a vendor to make the necessary repairs. Upon completion, the Program Manager will review the work for completion and verify, using the site audit in the subsequent month, that the issue is resolved. Should an emergency physical site issue arise, one that makes the home either unsafe or unlivable, the COO will be notified directly and if the issue or repair cannot be addressed immediately, the participant(s) will be relocated according to the individual¿s ISP and company policies and procedures. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate staff responsible for aforementioned process of their responsibilities to ensure the physical site of all community homes is maintained and not hazardous. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] |
03/15/2019
| Implemented |
| 6400.112(c) | The fire drill record for the drill held on 8/24/18 did not include the evacuation time of the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and then monthly thereafter, the House Manager will hold an unannounced fire drill, will complete the fire drill form and will submit the form to his or her respective Program Manager. The Program Manager will review the fire drill, and if not compliant with respect to all aspect of Fire Safety regulations, will instruct the House Manager to repeat the drill. If compliant, the Program Manger will submit the completed Fire Drill to the Chief Operations Officer (COO). The COO will log the completed fire drill on the excel spreadsheet located in the company¿s shared drive and will file the fire drill form in the master fire binder.[Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for conducting fire drills and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I). Documentation of the 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 2/19/19, did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | ACTION TO CORRECT VIOLATION: information concerning allergies collected and added to individual's record as an attachment to the physical examination. 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 2/19/19 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: medical information pertinent to diagnosis and treatment in case of emergency gathered from individual's physician and added to individual's record as an attachment to the physical examination. 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 |
| 6400.186(b) | Individual #1 did not sign the ISP reviews for review periods 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. ISP reviews for the 7-1-18 through 12-31-18 time period were reviewed with the individual. Verification that the individual's signature was documented as evidence of this review occurred 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 |
|
|