Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The agency did not complete a self-assessment of the home. | 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. | In order to correct this violation,FSU completed the self-assessment for residential site and used the self-assessment summary instructions for the timeline to complete, which it stated 3-6 months prior to inspection, opposed to license renewal. FSU has since corrected the due date on our calendar and will issue notification at our team meetings. Going forward FSU will hire a Compliance Manager which will be responsible for placing the due date on the calendar 6 months prior to the license renewal and share the date with House manager and the CEO. The House manager is responsible for making sure the self assessment is completed no less than 4 months prior to license renewal. [As of 8/10/18, the self assessment of the home was not completed. Prior to 3 months before the expiration date of the certificate of compliance, the CEO and house manager shall review completed self-assessments to ensure timely completion of the self- assessments to measure and record compliance with this chapter. Documentation of the reviews shall be kept. (DPOC by AES,HSLS on 9/7//18)] |
07/01/2018
| Not Implemented |
6400.21(a) | Chief Executive Officer #1, date if hire 7/1/17 had a Pennsylvania criminal history record check completed 7/27/17.
Program Specialist #2, date of hire 7/1/17 had Pennsylvania criminal history record check completed 7/27/17.
Direct Service Worker #3, date of hire 3/1/17, did not have a Pennsylvania criminal history record check. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| In order to correct this violation, Immediately, the CEO will develop and implement policies and procedures to include a new hire checklist including background checks to ensure that all required criminal background checks are completed as required and maintained and available for review. CEO will review all criminal background checks to ensure submission and completion as required within 5 working days after the person's date of hire.
Documentation of policies and procedures and reviews shall be kept. [Direct Service Worker #3 had a PA state police criminal record check completed on 6/29/2018. Documentation of the CEO's audit of criminal record checks shall be completed. Immediately and prior to hire and continuing at least quarterly, the CEO shall audit the "pre-employment checklist" to ensure completion with all required information including required criminal history checks. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 9/7//18)] |
07/05/2018
| Implemented |
6400.21(c) | Direct Service Worker #4, date of hire 7/1/17, had a Pennsylvania criminal history check dated 6/7/16; the criminal history check indicates a criminal record; however, the record was not attached. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| In order to correct this violation, Direct care worker #4 has summitted a new criminal clearance with all the attachments placed in direct worker#4 employee file. 6/29/2018 Going forward, the CEO has revised the new hire checklist to include the information and the steps required to hire an individual that has a prior criminal record. Hiring manager are required to take the online training to become knowledgeable. These steps are closely monitored by the CEO during the entire hiring process. All paperwork is required to be collected by the house manager and forwarded to the CEO for final review. Once all the pertinent documents are collected and reviewed by the CEO, only then can an employment offer be made.6/29/2018 [Direct Service Worker #4 had a PA state police criminal record check completed on 6/29/2018. Documentation of the CEO's audit of criminal record checks shall be completed. Immediately and prior to hire and continuing at least quarterly, the CEO shall audit the "pre-employment checklist" to ensure completion with all required information including required criminal history checks. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 9/7//18)] |
06/29/2018
| Implemented |
6400.31(a) | Individual #1, date of admission 3/17/18, was not informed of the individual's rights upon admission. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | In order to correct this violation, Individual #1 signed a revised rights form which included the missing rights 6/29/2018. Going forward, the program specialist will be responsible for having the individuals sign the "rights" both upon admission and annually. Program specialist will document on the new admission checklist. Annual documentation including "rights" is tracked on calendar by the Program specialist. CEO will review new admission checklists and tracking and compare to individual records to ensure timely completions of receipt of rights. [Individual #1 signed an individual rights document on 7/1/18. Documentation of audits of rights documentation, tracking system and individual records by the CEO shall be kept. (DPOC by AES,HSLS on 9/7//18)] |
06/29/2018
| Implemented |
6400.43(b)(4) | Chief Executive Officer #1 did not demonstrate compliance with Chapter 6400 regulations, related to Community Homes for people with Intellectual Disabilities. In addition, Chief Executive Officer #1 was not present during the scheduled annual inspection. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | In order to correct this violation, The CEO will be retained on the job responsibility per 6400.43(A)-(C) and policies and procedures of FSU organization. Chief Executive Officer #1 was not present during the scheduled annual inspection but will be present so forth on scheduled inspections. Going forward, FSU will hire a compliance officer to assist the CEO and administrative staff on tracking systems and compliance. Family services united board of director shall educate the CEO of the responsibilities of the position as per 6400.43(b)(1)-(4). Documentation of quarterly reviews shall be kept.7/9/2018 [As of 8/10/18 the CEO has not been trained in the CEO responsibilities and did not participate in the unannounced inspection by the Department on 8/10/18. The agency has not hired a Compliance Officer. Immediately, the CEO shall be educated in the responsibilities of the CEO position as per 6400.43(b)(1)-(4) to include a review of the 6400 chapter, the agency policies and procedures, the admission and discharge procedure. Documentation of the training shall be kept. as stated in POC. Quarterly review documentation not available for review. (DPOC by AES,HSLS on 9/7//18)] |
07/09/2018
| Not Implemented |
6400.44(b)(10) | Individual #1, date of admission 3/17/18, did not have monthly documentation of the individual's participation and progress towards outcomes. | 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. | In order to correct this violation, ISP Goal Data documentation has been implemented on 7/2/18. With this in place, a monthly review will be generated stating 7/2/18. This ISP review will be provided to all members of individual #1's team. Going forward CEO 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 10 days of receipt of the plan of correction, the CEO shall educate 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 will 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 shall be kept. 7/3/2018 [As of 8/10/18, the program specialist has not completed monthly reviews for individual #1 and the program specialist has not been educated of the responsibilities of the position. (DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Not Implemented |
6400.44(b)(18) | Program Specialist #2, did not ensure that direct service workers in the home were properly trained in the Health and Safety needs of Individual #1, admitted 3/17/18. This includes, but it not limited to, qualified and trained staff to administer medications. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | In order to correct this violation, the program specialist received a disciplinary action for not ensuring that direct service workers in the home were properly trained in the Health and Safety needs of Individual #1. This includes, but it not limited to, qualified and trained staff to administer medications., Moving forward the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44b (1)-(19). Documentation of the training shall be kept. Documentation of quarterly reviews shall be kept.7/5/18 [As of 8/10/18, the program specialist has not been educated of the responsibilities of the position and staff have not been trained in medication administration. A registered nurse is currently administering all medications. Immediately, the CEO shall ensure staff persons are trained on the health and safety needs relevant to each individual. Documentation of the training shall be kept. At least weekly for 3 months and at least weekly for 3 months after hire, the CEO and Program Specialist shall observe each staff person to ensure that all direct service workers are implementing the training in the health and safety needs relevant to each individual including administered medications as applicable. Documentation of the trainings and observations shall be kept.(DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Not Implemented |
6400.46(a) | Direct service worker #4, hired 7/1/17, did not have an 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. | 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. | In order to correct this violation, Direct service worker #4 had update orientation relevant to their responsibilities, the daily operation of the home and policies and procedures of FSU. Documentation of training was added to Direct service worker #4 employee file .7/2/2018 Going forward, CEO and program specialist will review all employees training records and documents on orientation. Program specialist and house manager was trained on a tracking system and reviewed all of 6400 training regulations. This will be the responsibility of the Program Specialist. The Program Director will review all staff files to ensure all staff have received orientation to each individual¿s needs, the homes policies/procedures and their specific job responsibilities, All training will be accurately documented in employee files and reviewed by CEO. Quarterly, the CEO shall review all training documents and staff training tracking document to ensure all required staff training is completed and documented as required .7/2/2018 [Direct Service worker #4 had training from 6/29/18 to 7/3/18. Documentation of aforementioned quarterly audits of staff training by the CEO shall be kept. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] |
07/02/2018
| Implemented |
6400.46(f) | Direct service worker #4, date of hire 7/1/17, did not have an initial fire safety training. | 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. | In order to correct this violation, Direct care worker#4 and program specialist has been trained in general fire safety, evacuation procedures, and responsibilities during fire drills. 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. as of 07/02/18. Documentation of trainings was added to Direct care worker#4 and program specialist employees¿ files. Going forward CEO and program specialist will review all employees training records and documents on fire safety. Program specialist and house manager was trained on a tracking system and reviewed all of 6400 training regulations. This will be the responsibility of the Program Specialist. Quarterly, the CEO shall review all training documents and staff training tracking document to ensure all required staff training is completed and documented as required7/2/18 [Direct service worker #4 had fire safety training on 7/18/18. Program specialist had fire safety training on 7/2/18. Documentation of aforementioned quarterly audits of staff training by the CEO shall be kept. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] |
07/02/2018
| Implemented |
6400.46(i) | Program Specialist #2, date of hire 7/1/17, was not trained in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. | 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. | In order to correct this violation,Program specialist was trained in CPR/First Aid didn¿t have a copy of certificate on site in personal file, Program Specialist employee file was updated.
Moving forward, FSU will ensure that all prospective employees receive training in First Aid/CPR before working with the Individuals/participants. FSU has contacted with a Certified CPR/FA instructor to coordinate schedule sessions prior to expiration date of staff certification to ensure no lapse in certification. This will allow for an unforeseen absence and the ability to reschedule if needed and still maintain current certification. The CEO will develop a new hire checklist ensuring that all required trainings are completed as outlined in the regulations within the prescribed timeframes within 10 days receipt of this plan of correction. [Program Specialist #2 was trained in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 7/24/18. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.67(b) | There was a red brick protruding approximately 4 inched above the top of a floor drain in the basement of the home posing a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | in order to correct this violation, The floor drain was properly covered with a new drain and bricks were removed.7/5/2018 Going forward, the house manager will be responsible to do monthly inspections for house repairs. The house manager will complete monthly inspection forms. [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads drain cover was replaced on 7/1/8. Document read pleas complete and return to CEO and House Manager for review. Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cordless telephone left of the fireplace in the living room of the home. The telephone numbers of the nearest hospital, police department, fire department, and ambulance were not on or by the cordless telephone to the right of the fireplace in the living room of the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| In order to correct this violation, the House manager reprinted the list of emergency numbers on and by any land line phone at the residential site. The list contains emergency numbers for the police, fire department, poison control center, closest hospital and fire department. To ensure on going compliance the CEO informed all staff to notify House manager if there are not emergency numbers located by a telephone at a residential site. During new hire orientation staff will trained on the location of emergency numbers and equipment. Completed 6/29/2018 (emergency numbers) Monthly, CEO will complete an on-site visit of residential site to ensure all required telephone numbers are on or by each telephone with an outside line. Documentation of on-site visits shall be kept. 6/29/2018 [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "all telephone numbers replaced, 6/29/18." Document read "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
06/29/2018
| Implemented |
6400.77(c) | There was not a first aid manual with the first aid kit in the kitchen of the home. | A first aid manual shall be kept with the first aid kit. | In order to correct this violation, First Aid manual has been placed in the first Aid kit. Going forward a procedure is in place that required the House manager and RN to do a walk through monthly to assure that all necessary regulatory items are in place. The first aid kit check will be added to the monthly checklist and the house manager will check to ensure all required item are in the first aid kit at least monthly. The Program specialist will review the monthly checklist at least quarterly to ensure completion and accuracy. Documentation of the checks shall be kept. 7/5/2018 [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "first aid manual purchased, 6/29/18." Document read "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.106 | The furnace in the home was not inspected and cleaned by a professional furnace cleaning company within the past year. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| in order to correct this violation, Furnace inspection was done by a certified HVAC inspector and approved on 7/3/2018. Documentation is on file. Going forward, the house manager will check annual tracking system at least quarterly to ensure timely completion of annual furnace inspection are scheduled and complete. CEO will assure furnace is inspected and approved annually by a HVAC expert. Documentation of the policies and procedures and checks shall be kept. [Furnace Inspection completed 7/3/18. A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "Annual inspection completed 7/3/18." Document reads "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Implemented |
6400.111(f) | The fire extinguishers in the kitchen, in the laundry area of the basement and at the top of the stairs outside of the bathroom were not inspected and approved by a fire safety expert and there were not dates of inspection on the fire extinguishers. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | In order to correct this violation, the CEO has scheduled a fire extinguishers inspection. All fire extinguishers will be inspected and tagged by a fire safety expert on 7/12/2018 at 1:00p.m. Going forward the CEO will ensure the fire extinguishers are tagged and inspected annually. (service receipts photo of inspection tags will be kept) [Immediately, the CEO shall develop and implement policies and procedures to include a tracking system and notification system and monthly checks of fire extinguishers. CEO will assure fire extinguishers are inspected and approved annually by a fire safety expert. Documentation of the policies and procedures and checks shall be kept. 7/12/18 [Fire extinguishers serviced and tagged on 7/12/18. A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "Annual inspection completed 7/12/18." Document reads "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.112(c) | The written fire drill records for the fire drill held from July 2017 to June 2018 did not include the exit route used 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. | In order to correct this violation, FSU has retrained staff on alternating exits and proper documentation for fire drills. Going forward FSU will keep a written fire drill record of the date, time, the amount of time it took for evacuation, the exit route used, alternating of exits, problems encountered and whether the fire alarm or smoke detector was operative. This will be the responsibility of the House manager. The compliance officer and house manager will review the fire drill documentation monthly to ensure compliance and maintain documentation for review by 7/4/2018 [Fire drills held on 6/29/18 and 7/18/18 include exits route used. Documentation of staff training on completing and documenting fire drills shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/04/2018
| Implemented |
6400.112(d) | The fire drill held on 4-14-18 had an evacuation time of 5 minutes. The fire drill held on 5-15-18 had an evacuation time of 3 minutes. There was no written documentation of an extended evacuation time by a fire safety expert. | 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. | In order to correct this violation, The Program Specialist and house manager retrained the staff and individual #1 on 7/4/2018. A fire drill test for evacuation time was done 7/4/2018 and individual #1 evacuation time was 2minutes. Going forward to speed up the evacuation time FSU will do frequent evacuation drills and train individual #1 on the important to take evacuation seriously for safety. if evacuation time is still not in compliance FSU will schedule for a fire safety expect for extended evacuation time. The Program Specialist will review the fire drill records during monthly team meetings and Trainings and Compliance Manager is responsible for reviewing the fire drill record for accuracy during the weekly compliance visit. Within 30 days of receipt of the plan of correction, the CEO or House manager shall observe a fire drill to ensure fire drills are conducted and documented as required.7/3/2018 [Fire drills held on 6/29/18 and 7/18/18 had evacuation times with in 2 1/2 minutes. Documentation of staff training on completing and documenting fire drills shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/04/2018
| Implemented |
6400.113(a) | Individual #1, date of admission 3/17/18, was not instructed in fire safety upon initial admission. | 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. | in order to correct this violation, Individual #1 has been trained on 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 documentation has been added to individual #1 file, Going forward, FSU will make sure that each individual, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, . The Program Specialist will confirm that individuals received the required Fire and Safety Training. The Program Director will review all the Individuals records bi-annually to ensure fire safety training has been completed. CEO will review new admission checklists and annual tracking system at least quarterly to ensure timely completion of initial and annual trainings are up to date.7/4/2018 [Individual was trained in fire safety on 6/29/18. Immediately, the CEO shall completed the aforementioned new admission checklist and annual tracking system. Documentation of all of aforementioned reviews by the program specialist, the program director and the CEO shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
07/04/2018
| Implemented |
6400.141(c)(3) | The physical examinations for Individual #1, dated 10/10/17 and 3/5/18, do not include a record of immunizations. This section was left blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | In order to correct this violation, Individual #1 received The Tetanus shot and her file was updated on 06/29/2018. Going forward CEO will ensure all individuals at FSU will have completed immunizations before moving into a residential site. The current intake form used at FSU list immunizations are a requirement. All administrative staff will be train on this regulation to be compliant. An bi annual appointment checklist was created, and also a tracking system was put in place to assure that all medical needs are met and in compliance. Immediately, the CEO shall train Program Specialist and the House manager of the requirements of individuals physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the reviews of physical examinations shall be completed, and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. [As of 8/10/18 Individual #1's physical examination does not include immunizations and there is not a record of the immunization purchased (Boostrix injection 0.5mL (DTAP) being administered. Immediately, implement aforementioned plan of correction. (DPOC by AES, HSLS on 9/7/18)] |
07/02/2018
| Not Implemented |
6400.151(a) | Program Specialist #2, date of hire 7/1/17, did not have a physical examination. Direct service worker #4, date of hire 7/1/17, did not have a physical examination. | 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. | Program Specialist#2 and Direct care worker #4 has provided copies of pre-employment physicals 07/3/2018 all employee records gas been updated. Going forward, the CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire files to assure that the physical form and criminal background is on file. Documentation of the reviews shall be kept ensuring staff physicals are completed timely. Tracking system is in place to remind program specialist when staff files needs updated 7/3/2018 [Program Specialist #2 had a physical examination completed 10/20/17 and Direct Service Worker #4 had a physical examination completed 6/29/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Implemented |
6400.151(c)(2) | Program Specialist #2, date of hire 7/1/17, did not have Tuberculin skin testing. Direct service worker #4, date of hire 7/1/17, did not have Tuberculin skin testing. | 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. | In order to correct this violation, Immediately, Program Specialist #2 and Direct care staff #4 has provided copies of pre-employment physicals 07/3/2018 which included TB testing. The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical with TB testing completed on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form and criminal background is on file. Documentation of the reviews shall be kept ensuring staff physicals are completed timely. Tracking system is in place to remind program specialist when staff files needs updated 7/3/2018 [Program Specialist #2 had a Tuberculin skin testing completed 10/19/17 and Direct Service Worker #4 had a physical examination completed 7/2/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination including Tuberculin skin testing and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)]] |
07/03/2018
| Implemented |
6400.151(c)(3) | Direct service worker #3's physical examination, completed 3/8/18 did not include a statement that the employee is free from a communicable disease 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. | 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. | In order to correct this violation (7/3/2018 House manager had new physical form documentation from physician stating she was free from communicable disease. Going forward, The CEO will ensure all employee physicals are accurate during the new hire process. CEO will ensure all physicals have a section that state the employee is free of communicable diseases that a health professional must address during the physical Immediately and prior to entering into staff files, the CEO shall review all staff physical examinations to ensure all required information is present and there are not any required areas left blank including communicable disease. Documentation of reviews shall be kept. 7/3/2018 [Program Specialist #2 had a physical examination including a signed statement that the staff person is free of communicable diseases completed 10/20/17 and Direct Service Worker #4 had a physical examination including a signed statement that the staff person is free of communicable diseases completed 6/29/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information including 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 completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Implemented |
6400.163(c) | Individual #1, date of admission 3/17/18, is prescribed medications to treat symptoms of diagnosed Anxiety, Depression, and Intermittent Explosive Disorder; however, the individual has not had a review with a licensed physician regarding the reasons the medication is prescribed, the need to continue the medication, or the necessary dosages of prescribed medications. | 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. | In order correct this violation the Program Specialist created a quarterly psychiatric medication review form to be completed quarterly for psychiatric medications. For individual # 1 the most recent psychiatric medication review was 7/3/2018. Going forward the form must be completed quarterly. (psychiatric medication quarterly review form) Immediately, the CEO will develop and implement policies and procedures to include a tracking, notification, review and training to ensure medication reviews are completed timely with all required information. Documentation of aforementioned policies and procedures shall be kept. 7/3/18 [Individual #1 had a psychiatric medication review completed 7/3/18 to include all required information. Upon completion of the psychiatric medication review by the licensed physician, a designated staff person certified to administer medications and trained in the requirements of psychiatric medication reviews as per 6400.163(c) shall audit all psychiatric medication reviews to ensure all required information is included and individuals are administered medications as prescribed. Documentation of audits shall be kept. Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Implemented |
6400.167(a) | Direct service worker #3, who is not certified to administer medications, administered medications to Individual #1 from 3/17/18 to 6/28/18. Direct Service worker #5, who is not certified to administer medications, administered medications to Individual #1 from 3/17/18 to 6/28/18. Individual #1 has not been assessed to self-administer medications. | 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. | In order to correct this violation, After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Registered nurse will pass all meds until all staff are med trained. All staff who were not properly certified to administer medications ceased administering medications that same day. FSU continued to implement the steps of the plan of correction until all staff are certified to administer medications. Going forward, the RN will become a medication administration trainer next available class. RN will review all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The RN is responsible for maintaining documentation and records on an ongoing basis. quarterly for 1 year, the CEO 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. Documentation of all review shall be kept 6/28/2018 [A registered nurse is currently administering all medications. Documentation of Medication Administration training for direct service workers not available for review. Immediately, implement aforementioned submitted plan of correction. (DPOC by AES, HSLS on 9/7/18)] |
06/28/2018
| Implemented |
6400.181(a) | Program Specialist #2 did not complete an assessment for Individual #1, date of admission 3/17/18. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program Specialist completed individual # 1 assessment on 7/5/2018 as per 6400.181 (a)-(f).Going forward to ensure on going compliance with this violation the Program Specialist and CEO will determine the assessment due date during the intake process. This will ensure the Program Specialist is aware of when the assessment must be completed to be compliant. All administrative staff will be trained on this regulation during new hire orientation and annually. Individual #1's assessment was completed on 7/5/18. Within one week of receipt of the plan of correction and at least quarterly for one year and annually thereafter, the CEO/program specialist shall review the responsibilities of the position as per 6400.44(b)(1)-(19) and sign and date upon review. Within 30 days of receipt of the plan of correction the CEO shall develop and implement a new admission and annual checklist to include a tracking system to ensure timely completion of initial and annual requirements including assessments. At least monthly the CEO shall review the tracking to ensure timely completion of assessments. Documentation of reviews shall be kept. [Individual's assessment was completed 6/30/18.Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.186(a) | Program Specialist #2 did not complete an ISP review for Individual #1, date of admission 3/17/18. | 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. | In order to correct this violation, Program Specialist#2 has completed the 3-month ISP review for Individual #1 on 07/5/2018. Going forward the CEO has created a tracking system to document when the three-month reviews are completed coinciding with the ISP dates. The Program specialist will review the regulations 6400. 186, (a) through (g) pertaining to the ISP Review and Revision. The program specialist will contact the Supports Coordinator to develop a timeline for the ISP and 3-month reviews and will send them to all team members. At the Annual ISP, the program specialist will complete the declination form with the team members.
Program Specialist will conduct a quarterly review of all records to ensure that the necessary signatures are obtained. In addition, the House manager and compliance office will conduct spot checks of files to ensure compliance. Immediately, the program specialist and Individual #1 shall review the ISP review and sign and date as required. Within 15 days of receipt of the plan of correction, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44b (1)-(19). Documentation of the training shall be kept. Documentation of quarterly reviews shall be kept. 7/26/18 [The program specialist completed an ISP review for Individual #1 on 6/29/18. Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] |
07/05/2018
| Implemented |
6400.186(e) | Program Specialist #2 did not notify Individual #1's plan team members of the option of the option to decline ISP reveiws. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | In order to correct this violation, a signature form has been created for SC to sign and indicate a copy, agree and/or if declined to review. The form will be filed with the reviews and reviewed by CEO and program specialist. Program Specialist will email all team members the option to decline ISP reviews. Going forward to stay in compliance the program specialist will ensure the option to decline letter is sent to team members once the individual has completed the intake process. CEO will review the intake documentation to ensure the individuals team members will be sent the option to decline letter. The program specialist notified the plan team members for Individual #1 of the option to decline the ISP review documentation on 7/3/2018 via email. Within one week of receipt of the plan of correction and quarterly for 1 year, the CEO will review with the program specialist the responsibilities of the position as per regulation 6400.44(b)(1)-(19) and sign and date upon review. Documentation of the CEO's review of options to decline shall be kept.7/10/2018 [The program specialist notified the plan team members of the option to decline ISP review documentation on 6/28/18.Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] |
07/03/2018
| Implemented |
6400.213(9) | Individual #1's record did not include a copy of the current ISP for Individual #1. | Each individual's record must include the following information: A copy of the current ISP. | To correct this violation, program specialist #2 contacted SC for Individual #1's record was updated to include current ISP Immediately, Going forward Program specialist shall review individual records to ensure all required information as per 6400.213(1)-(14) is present including copy of ISP. Documentation of all reviews shall be kept. 6/29/2018 The program specialist will ensure during the intake process of admittance, A updated ISP will be in individuals files. Once the intake information is gathered the CEO will review the individual's file to check for accuracy as per 6400.213(1)-(14). This change was made effective as of 6/29/2018, by the CEO.
Regarding individual files administrative staff will be retrained how to keep individuals files up to date how to identify missing information. as per 6400.213(1)-(14) [As of 8/10/18, Individual #1's current ISP was in Individual's Record. Immediately and continuing at least quarterly, a designated staff person trained in the information required to be in the individuals' records shall audit all individuals' record to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/7/18)] |
06/29/2018
| Implemented |