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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.74 | The three wooden steps leading from the porch on the side of the home to the front yard did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| ACTION TO CORRECT VIOLATION: Non-skid strips were applied to the stairs on 3-15-19. ACTION 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)] |
03/20/2019
| Implemented |
| 6400.112(c) | The fire drill record for the fire drill held on 8/24/18 did not include the amount of time it took for evacuation. | 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. | ACTION TO CORRECT VIOLATION: It is believed that the employee who conducted the August 2018 fire drill left the area next to "minutes" blank because the time to evacuate was only 48 seconds. Instead of leaving it blank, the employee should have written the number "0" in this space. ACTION 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. |
03/20/2019
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed on 3/27/18, did not include the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | ACTION TO CORRECT VIOLATION: To correct the absence of necessary information on this individuals physical examination, information regarding health maintenance needs, medication regimen and the need for blood work at recommended intervals was gathered and added to the individual's medical record and verified to be present on 3-29-19. ACTION TO PREVENT FUTURE OCCURENCE: As of March 20, 2019, the agency¿s Annual Physical Exam form was updated to include an area for assessing the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals. 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.141c15 [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)(13) | Individual #1's physical examination completed on 3/27/18, did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | ACTION TO CORRECT VIOLATION: To correct the absence of detail regarding allergies and contraindicated medications on this individual's physical examination form, information was gathered and added to her medical record and verified to be present on 3-29-19. ACTION TO PREVENT FUTURE OCCURRENCE: 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.141c15 [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 3/27/18, 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 correct the absence of necessary information included in this individuals physical examination, detailed information regarding emergency information pertinent to her diagnoses was gathered and added to her record and verified to be present on 3-29-19. ACTION TO PREVENT FUTURE OCCURRENCE: 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 |
| 6400.141(c)(15) | Individual #1's physical examination completed on 3/27/18, did not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | ACTION TO CORRECT VIOLATION: To correct the absence of Information reflected on her physical examination, detailed information regarding this individual's diet needs was gathered and added to her record. Information was verified to be present on 3-29-19. ACTION TO PREVENT FUTURE OCCURRENCE: As of March 20, 2019, the agency¿s Annual Physical Exam form was updated to include an area for special instructions for the individuals¿ diets. 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 review for review period from 9/1/18 to 1/31/18. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | ACTION TO CORRECT VIOLATION: Program Manager reviewed ISP review reports for 9/1/18 through 1/31/19 with the individual. Individual signatures were verified as present on 3-29-19. ACTION TO PREVENT FUTURE OCCURRENCE: 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 |
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