| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | At the time of licensing on 2/14/19, the self-inspection of the 1203 Creekside Drive home did not include a date when it was completed to show compliance with the time frame indicated in this regulation. The self-assessment must be completed within 3-6 months prior to the expiration of the date of the agency's certification of compliance that occurred on 12/28/18. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The self-inspection of the 1203 Creekside Drive home did not state the date when it was completed to show compliance. During the 2/15/19 inspection, the CEO immediately dated the self-assessment. It will now be the responsibility of the Executive Director to complete the Agency¿s self-assessments dating and signing them. All administrative staff will be re-trained on this regulation. This will be completed by 4/1/19. (See Attachment #4). The CEO will oversee this corrective action step with documentation by 5/1/19. |
04/01/2019
| Implemented |
| 6400.22(f) | On Individual #2's February 2019 financial log, staff noted on 2/12/19 that the "individual owes Staff #1 $7.06 for conditioner and a scarf that was purchased." Staff #1 purchased the items with her money for the individual. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | Staff #1 commingled her money when buying Individual #2 personal items. An immediate plan of correction took place by retraining Staff #1 on 6400.22(f) and Bethel Care¿s Financial Policy. This corrective action was completed 2/25/19. (Attachment #19 - Staff #1¿s Signed Re-training on Financials Form) The Program Specialist and CEO will re-train all DSP staff on this regulation and Bethel Care¿s Financial Policy.(Attachment #4) This step will be completed by 4/1/19. As oversight, the CEO will review this regulation and Policy with each staff person between 4/1/19 and 5/30/19. |
04/01/2019
| Implemented |
| 6400.31(a) | Individual #2's date of admission to the facility was 8/19/18 and there was no documentation that the individual was informed of their rights upon admission. The individual signed and dated documentation in their record that indicated the individual was informed of their rights on 8/20/18. | 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. | Individual #2's date of admission to the facility was 8/19/18, rather the documentation that the individual was informed of their rights date 8/20/19. The Program Specialist will create a check list of all forms, agreements, documentation, etc. which needs to be addressed with each new enrollee. (Attachment #14) This checklist will be used for each new enrollee entering in to services with Bethel Care. Another corrective action step is that all Bethel staff will be retrained on this regulation and Bethel¿s implementation. This corrective action step will be completed by 4/1/19. (Attachment #4) The CEO will give review the charts made for the two individuals and oversee the other corrective action steps by 5/30/19. |
04/01/2019
| Implemented |
| 6400.43(b)(3) | According to 8/28/18 hospital discharge instructions in Individual #1's record, "patient was seen due to suicidal thoughts and threatening to jump in front of a car this morning. Patient reports having a bad morning and voiced wanting to kill himself/herself to their father and also ran out of the house and tried to get hit by a car." The incident report entered by the agency for 8/29/18 indicated "the individual was going to kill himself/herself that night and that the individual was going to stab himself/herself. The individual fled the house. The individual was seen by a psychiatric nurse on 8/31/18 and there was discussion concerning the individual. The conclusion being that the individual's episode was the mix of historical-physiological occurrences, the trigger of getting a new roommate into the home, and having changed prescribed medications within the last two weeks."
Individual #1 returned home to the residential facility on 8/28/18 after the specific threats to harm oneself. The residential facility did not lock up knives, sharp objects, increase supervision levels, or put alarms on egress doors in the homes to ensure Individuals' #1 and #2's safety.
According to additional incident reports entered by the agency, Individual #2 was witnessed sticking out their tongue at Individual #1 on 9/6/18 and on 8/30/18 Individual #2 was asking repeated personal questions about Individual #1's past that they did not want to talk about. There was increased tension being documented in both individual's records that was not addressed in the home. The full reports are entered into the Enterprise Incident Management system with ID numbers 8489741 and 8489742.
According to Individual #2's 11/20/18 Individual Support Plan (ISP) review and Individual #1's incident #8470071, it was documented that on 9/13/18 another incident took place between Individual #1 and #2 in the home. The result was that Individual #1 had access to a knife, grabbed the knife, lunged at Individual #2 and Individual #1 indicated they wanted to kill Individual #2. The knives were still accessible to the individuals on 9/13/18 after the first documented threat of harm from Individual #1 on 8/28/18. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | It is the CEO¿s responsibility for the safety and protection of the individuals. The residential facility did not lock up knives, sharp objects, increase supervision levels, or put alarms on egress doors in the homes to ensure Individuals' #1 and #2's safety. Since the 2/14/19 inspection, the locking of sharp objects has been added to Individual #1¿s behavior support plan and is in the process of being added to the ISP. Both Individual #1 and #2 reside now in different facilities. To correct this error, and to better serve Individual #1, the Program Specialist has become a certified Crisis Prevention Intervention trainer and will have all Bethel Care staff trained on nonviolent crisis intervention techniques by 3/9/19. (Attachment #17- Staff Crisis Prevention Training) |
03/09/2019
| Implemented |
| 6400.46(a) | Staff #2's date of hire was 12/28/17 due to obtaining a licensing certificate with an operation license starting on 12/28/17. It was documented that the staff didn't have training to staff responsibilities, daily operations of the home and policy and procedures until 5/1/18. | 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. | Staff #2 did not receive orientation training relevant to their responsibilities, the daily operations of the home and policy and procedures until 5/1/18, when the hire date was 12/28/17, the date of the license certificate. Orientation training will take place before the date of hire of all staff. Step one of the corrective plan to ensure that this does not occur again is that each file of every applicant with pending employee status will contain an Employee Tracking Chart (Attachment #10) which includes the orientation training date. This corrective action step will be completed by 3/5/19. Secondly, the CEO will review all employee files to ensure this form is contained therein. This step shall be completed by 5/30/19 |
03/05/2019
| Implemented |
| 6400.46(c) | Staff #2's date of hire was 12/28/17 due to obtaining a licensing certificate with an operation license starting on 12/28/17. She only had documented 16 hours of training from 12/28/17 until current (2/14/19). | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Staff #2 did not receive 24 hours of training relevant to human services or administration within the first year of hire. To prevent future occurrences, the Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid), and for the CEO it will also include 24 hours of annual training relevant to human services or administration. The CEO will retrain all staff of this regulation. These steps will be completed by 4/1/19. (see Attachments #4 and #10) The CEO will oversee the implementation of this step by 5/30/19. Secondly, the CEO will review all employee files to ensure this form is contained therein. This step shall be completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.46(e) | Staff #2's date of hire is 12/28/17, due to obtaining a licensing certificate with an operation license starting on 12/28/17, and didn't have training in the areas of intellectual disability, the principles of integration, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Her training in these areas was completed on 5/1/18. | 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. | Staff #2 didn't have mandatory training within 12 months prior or within 30 calendar days of hire date as stated in this regulation. The Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (See Attachment #10) The CEO or Executive Director will retrain all staff on this regulation. These steps will be completed by 4/1/19. (Attachment #4) The CEO will oversee the implementation of this step by 5/30/19. |
04/01/2019
| Implemented |
| 6400.46(f) | Staff #2, who provided direct support to Individual #1 since their move in date of 5/28/18, didn't have fire safety training on general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department until 6/1/18. | 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. | Staff #2, who provided direct support to Individual #1 since their move in date of 5/28/18, didn't have mandatory training as stated in this regulation until 6/1/18. The Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). The Program Specialist will retrain all staff on this regulation. (Attachments #4 and #10) These steps will be completed by 4/1/19. The CEO will oversee the implementation of this step by 5/30/19. |
04/01/2019
| Implemented |
| 6400.46(i) | Staff #2's date of hire was 12/28/17. Staff #2 also provided direct support to Individual #1 since the individual's date of admission on 5/28/18. Staff #2 didn't received training 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 until 9/10/18. | 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. | Staff #2 did not receive training in in first aid, Heimlich techniques and cardio-pulmonary resuscitation until 9/10/18 when the hire date of Staff #2 was 12/28/17. This training is to be completed within six months of the hire date. As a quality measure and to prevent future occurrences, the Program Specialist will create a chart which includes hire dates and a schedule for mandatory trainings, including first aid, Heimlich techniques and cardio-pulmonary resuscitation. This chart will be kept in office and each staff person will receive a copy with their own schedule. This step will be completed by 4/1/19. The Program Specialist will train all staff on this regulation by 4/1/19. The CEO will oversee the implementation of this step by 5/30/19.
(Attachments #4 and #10) |
04/01/2019
| Implemented |
| 6400.72(b) | The screen in the front screen door contained multiple holes and rips in the screen over the entire surface. The metal surface on the bottom of the front screen door was dirty. | Screens, windows and doors shall be in good repair. | All screens, windows and doors shall be in good repair. The CEO will have the screen in the front screen door repaired and the metal surface on the bottom of the front screen door cleaned. This corrective Action will be completed by 4/1/19. Reparations will be submitted as evidence of this POC by 4/1/19. (See Attachment #21-¿Reparations to Front screen door.¿) As a quality measure a list will be at the home location for staff to document ¿Suggested repairs and maintenance.¿ This step will be completed by 4/1/19. (See Attachment #20, ¿Repair and Maintenance Suggestion List.¿) CEO will provide a level of oversight by reviewing this list monthly and will write up an assessment stating what action will be taken. This corrective action step will be completed by 5/30/19 |
04/01/2019
| Implemented |
| 6400.80(a) | The rear egress walkway/path through the grass was completely covered in snow. The rear path egress leads to the front of the home that was blocked by a large pile of snow. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | It is the responsibility of DSPs who work in the home to make sure that outside walkways shall be free from ice, snow, obstruction and other hazards. The rear egress walkway/path through the grass to the front of the home was blocked covered and blocked by snow. First, immediate removal will be made to open and clear this pathway. This will be done 3/5/19. See picture of pathway. Second, a chart check-in chart will remain at the home which each DPS staff will mark whether the egress(es) are clear. This corrective action will be completed by 3/5/19. See (Attachment #18-Photos of Clear Egress). Thirdly, all DSP staff will be retrained on Fire Safety, including clear egress from the home. This corrective action will be completed by 4/11/19. The CEO will oversee the implementation of this training by 5/30/19. |
04/01/2019
| Implemented |
| 6400.104 | Both Individuals, #1 and #2, require verbal prompting to evacuate the home during a fire drill. The home did not notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The local fire department was not contacted via letter informing of the address of the home with the exact locations of the bedrooms of the individuals who need assistance evacuating in the event of a fire. An immediate letter has been written and sent to the local fire department containing such information, 2/25/19. ¿Letter to Fire Dept.¿ (Attachment #16 - Letter to Fire Dept.) The CEO will confirm that this plan of correction has been done by 2/25/2019. All Bethel Care Staff will be re-trained on this regulation by 4/1/19. |
02/25/2019
| Implemented |
| 6400.111(a) | The first and second floors of the home were not equipped with a fire extinguisher with a minimum 2-A rating. The fire extinguishers on both floors only contained a 1-A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The fire extinguishers on both floors were not those compliant within regulation. A fire extinguisher with a minimum 2A-10BC rating shall be located on both floors. As corrective action to this the House Manager will purchase two new fire extinguishers with a minimum 2A-10BC rating and be placed in the kitchen of the home. This will be completed by 3/5/19. All staff will be retrained on this regulation by the CEO by 4/1/19. (Attachment #4) The CEO will affirm that this has been completed by 5/30/19 |
04/01/2019
| Implemented |
| 6400.111(c) | The kitchen in the home was not equipped with a fire extinguisher with a minimum 2-A rating. The fire extinguisher in the kitchen only contained a 1-A rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. As corrective action to this the House Manager will purchase a fire extinguisher with a minimum 2A-10BC rating and be placed in the kitchen of the home. This will be completed by 3/5/19. All staff will be retrained on this regulation by the CEO by 4/1/19. (Attachment #4) The CEO will affirm that this has been completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.112(a) | Individual #1 moved into the residential home on 5/28/18 and Individual moved into the residential home on 8/19/18. A fire drill was not held in May and June 2018. | An unannounced fire drill shall be held at least once a month. | Individual #1's date of admission was 5/28/18 and a fire drill was not conducted As a corrective action and to ensure safety, a Fire Drill Tracking Chart will be created by the CEO or Executive Director. This Chart will be a tool to assist with timely execution of this regulation. CEO will retrain all staff on this regulation. This step will be completed by 4/1/8. CEO will review Chart, conducted Fire drills, and affirm trainings by 5/30/19. (See Attachment #15 - Fire Drill Tracking Chart) |
04/01/2019
| Implemented |
| 6400.112(c) | -The following fire drill records did not include documentation of the time the fire drill was held: 11/29/18, 12/29/18 & 1/14/19.
-The 11/29/18 fire drill record did not indicate the time of day, AM or PM, that the drill was conducted. The record only indicated "5:15" for when the drill was conducted. | 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. | Every fire drill should record 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.
Several fire drills did not contain all of this information. As a corrective action and to ensure safety, the CEO will review monthly fire drills on a monthly basis. Also, the CEO will create a Fire Drill Chart documenting if each fire drill was executed in a timely manner and its documentation is complete.(Attachment #15) Thirdly, as a corrective action CEO will retrain all staff on this regulation and conduction of fire drills.(Attachment #4) These steps will be completed by 4/1/8. CEO will review Chart and affirm trainings by 5/30/19. |
04/01/2019
| Implemented |
| 6400.112(e) | Individual #1 moved into the residential home on 5/28/18 and a fire drill was not held during sleeping hours until 1/14/19, outside the every 6 month time frame. A fire drill during sleeping hours should have been conducted in October 2018. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. Individual #1's date of admission was 5/28/18 and a fire drill was not conducted during sleep hours within the first six months. As a corrective action and to ensure safety, a Fire Drill Tracking Chart will be created by the CEO or Executive Director. This Chart will be a tool to assist with timely execution of this regulation. CEO will retrain all staff on this regulation. These steps will be completed by 4/1/8. CEO will review Chart, conducted Fire drills, and affirm trainings by 5/30/19. (See Attachments #4 and #15) |
04/01/2019
| Implemented |
| 6400.113(a) | Individual #1's date of admission was 5/28/18 and did not receive training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building and smoking safety procedures until 6/15/18. | 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. | Individual #1's date of admission was 5/28/18 and did not receive training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building and smoking safety procedures until 6/15/18. This should have been done upon initial admission and reinstructed annually in general fire safety. As a corrective action and to ensure safety, a Fire Drill Tracking Chart will be created by the CEO or Executive Director. (Attachment #15 - Fire Drill Tracking Chart) This Chart will be a tool to assist with timely execution of this regulation. The CEO will retrain all staff on this regulation. This step will be completed by 4/1/8.(Attachment #4 -Staff Signed 6400 Trainings) CEO will review the Chart and affirm trainings by 5/30/19. |
04/01/2019
| Implemented |
| 6400.141(a) | Individual #2's date of admission is 8/19/18 and the individual/individual's record did not have a physical examination completed until 9/25/18. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2's date of admission is 8/19/18 and the individual/individual's record did not have a physical examination completed until 9/25/18. The Program Specialist will create a check list of all forms, agreements, documentation, etc. which needs to be addressed with each new enrollee. (Attachment #14 - Enrollee Checklist) This checklist will be used for each new enrollee entering in to services with Bethel Care. Also, all Bethel staff will be retrained on this regulation. These steps shall be completed by 4/1/19. The CEO will oversee the execution of these steps as well as review any new enrollee physicals. This last step will be completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.141(c)(1) | Individual #1's 7/11/18 physical examination form only indicated the individual's medical history to be a diagnosis of Developmental Disabilities, Bipolar Disorder and ADHD. According to the individual's 6/26/17 and 6/27/18 vision examination forms, the individual has additional diagnosis of Type 2 Diabetes, Bilateral Myopia and Vitreous Degeneration of the left eye. According to the individual's 9/21/17 physical examination form, they are also diagnosed with Morbid Obesity, Depression and included past surgeries of deviated septum adenoidectomy and polypectomy. Individual #1's record also included primary care physician's appointment forms that included diagnoses of Hyperglyceridemia, triglycerides raised, Obstructive Sleep Apnea, Anemia, eating disorder, irregular periods, allergic rhinitis, Autism Spectrum Disorder, Oppositional Defiant Disorder, Diabetes Mellitus and severely obese. | The physical examination shall include: A review of previous medical history. | The accuracy of the physical examination for Individuals is the responsibility of the Program Specialist. There were additional diagnoses found in the record that were not on the physical form. The Program Specialist will amend the physical form adding the additional diagnoses found by licensing in the Individual¿s record. (see Attachment #14 - Enrollee Checklist) This corrective action will be completed by 3/5/19. The Program Specialist will review the physical of Individual #2. The CEO will give oversight of this corrective action by 5/30/19 |
04/01/2019
| Implemented |
| 6400.141(c)(6) | Individual #1's date of admission was 5/28/18 and did not receive a Tuberculin skin test with negative results until 7/13/18; after admission to the facility. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The accuracy of the physical examination for Individuals is the responsibility of the Program Specialist. Individual #1's date of admission was 5/28/18 and did not receive a Tuberculin skin test with negative results until 7/13/18; after admission to the facility. For new enrollees, it will be the CEO¿s responsibility to obtain the current physical and negative tb test prior to enrolling the individual into the facility. (see Attachment #14- Enrollee Checklist) The Program Specialist will be trained along with the entire Bethel Care Staff on this regulation by 4/1/19. The CEO will give oversight of this corrective action by 5/30/19 |
04/01/2019
| Implemented |
| 6400.141(c)(7) | individual #1's 7/11/18 physical examination form did not include a gynecological and pap test. The field was left blank. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | It is the responsibility of the Program Specialist to ensure the accuracy and oversight of the completion of the physical examination for Individuals. (See Attachment 14 - Enrollee Checklist) This Individual¿s physical test did not have an information concerning a gynecological and pap test. As corrective actions for this the CEO will retrain the Program Specialist and all staff on what a physical examination for an Individual should contain. This corrective action will be completed by 4/1/19.(Attachment #4- Staff Signed 6400 Trainings) |
04/01/2019
| Implemented |
| 6400.141(c)(13) | Individual #1's 7/11/18 physical examination form indicated "nkda" however their 2017 physical examination form listed "nkda, dogs, dust, mold and grass" under the allergy section. The individual's current list of allergies was not included on their 2018 physical examination form. | The physical examination shall include: Allergies or contraindicated medications. | The accuracy of the physical examination for Individuals is the responsibility of the Program Specialist. The individual's current list of allergies was not included on their 2018 physical examination form. The Program Specialist will amend the physical form adding the additional allergies found by licensing in the Individual¿s record. This corrective action will be completed by 3/5/19. The Program Specialist will review the physical of Individual #2. The CEO will give oversight of this corrective action by 5/30/19. |
03/05/2019
| Implemented |
| 6400.141(c)(14) | Individual #2's 9/25/18 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The accuracy of the physical examination for Individuals is the responsibility of the Program Specialist. Medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. The Program Specialist will amend the physical form adding the medical information pertinent to diagnosis found by licensing in the Individual¿s record. See corrective action This corrective action will be completed by 3/5/19. All Bethel Care Staff will be retrained on this regulation by 4/1/19. The Program Specialist will also review the physical of Individual #2. The CEO will give oversight of this corrective action by 5/30/19. |
04/01/2019
| Implemented |
| 6400.141(c)(15) | Individual #1's 9/25/18 physical examination form did not include the individual's diet. This section was left blank. | The physical examination shall include:Special instructions for the individual's diet. | It is the responsibility of the Program Specialist to ensure accuracy of the individual¿s physical. Individual #1¿s physical exam form did not include the individual's diet. This section was left blank. The Program specialist will correct the physical examination adding information in the diet section by 3/5/19. The Program Specialist and all staff will be re-trained on this regulation by 4/1/19. The CEO will give oversight of this corrective action by 5/30/19. |
04/01/2019
| Implemented |
| 6400.142(c) | -Individual #1's 6/4/18 dental appointment did not document the follow up treatment recommended. The individual had another dental appointment on 7/17/18 for "#18-B Resin n3. No la" but no indication of what procedure was completed on 7/17/18 or if there was additional follow up treatment recommended at the 7/17/18 appointment.
-Individual #2's 12/12/18 dental examination record does not include follow up treatment recommendations. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | Individual #1 and #2¿s dental examinations did not include follow up treatment recommendations. It is the responsibility of the Program Specialist to track follow-up on all physician visits. The Program Specialist will use a physician¿s communication log to track required/suggested follow-up visits. (Attachment #13 - Physician¿s Communication Log). All staff will be re-trained on this regulation by 4/1/19 (Attachment #4 - Staff Signed 6400 Trainings) This step of the corrective action will be completed by 4/1/19. Bethel Care will hire a medical coordinator by 5/1/19 to help with the medical documentation overflow. |
04/01/2019
| Implemented |
| 6400.144 | Individual #1's 8/28/18 discharge paperwork from their hospital visit indicated to follow up with the individual's primary care physician in 3-5 days. This was never completed.
-It was noted in Individual #2's record and reported from residential staff during the inspection, that Individual #2 occasionally chokes and vomits on food while eating. The agency indicated they have cut food into bite-sized pieces for the individual. However this medical situation was never addressed with Individual #1's primary care physician, hospital, or specialist. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| It is the responsibility of the Program Specialist to follow up with the Individual¿s primary care physician if the discharge instructions say to do so. The Program Specialist will create a physician¿s communication log that will note the follow-up required at each visit. (Attachment #13 - Physician Communication Log) by 4/1/19. Bethel Care Homes & Services, LLC will hire a medical coordinator by 5/1/19. |
04/01/2019
| Implemented |
| 6400.151(a) | Staff #2's date of hire is 12/28/17 due to their licensing certificate being approved with a licensing operation start date of 12/28/17. Staff #2 did not have a physical examination completed until 1/8/18. | 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. | Staff #2¿s physical exam was not completed until 11 days after he/she received the certificate to operate a residential facility. To prevent future occurrences, the Program Specialist will create an Employee Tracking Chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (Attachment #10 - Employee Tracking Chart) The CEO will retrain all staff of this regulation. These steps will be completed by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) The CEO will oversee the implementation of this step by 5/30/19 |
04/01/2019
| Implemented |
| 6400.151(b) | Staff #1's 4/2/18 physical examination form and Staff #2's 1/8/18 physical examination form was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff #1¿s and Staff #2¿s physical examinations were completed and signed but not dated by the physician. The Program Specialist will send both examination forms back to the doctor to have him date it. (Attachment #11 Staff #1 physical) (Attachment #12 - Staff #2 Physical) The Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (Attachment #10 - Employee Tracking Chart) It will be the CEO or Executive Director¿s responsibility to make sure the physical examination was signed by the doctor. The CEO or Executive director will re-train all staff on this regulation. This corrective action will be completed by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) The CEO will oversee the implementation of this step by 5/30/19 |
04/01/2019
| Implemented |
| 6400.151(c)(2) | Staff #2's date of hire is 12/28/17 due to receiving a certificate to operate a residential facility with a start date of 12/28/17. She did not receive a Tuberculin skin test with negative results until 1/10/18. | 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. | Staff #2¿s tuberculin test was not completed until 13 days after she received her certificate to operate a residential facility. To prevent future occurrences, the Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (Attachment #10 - Employee Tracking Chart) The Program Specialist will retrain all staff of this regulation. These steps will be completed by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) The CEO will oversee the implementation of this step by 5/30/19. |
04/01/2019
| Implemented |
| 6400.151(c)(3) | Staff #2's 1/10/18 physical examination form did not include if she was free from communicable diseases. The field was left blank. | 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. | Staff #2¿s physical examination will be faxed to the doctor so he/she can indicate whether staff #2 is free of communicable diseases or that he/she 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. This step will be completed by 4/1/19. The accuracy of the physical examination form will now be the duty of the Program Specialist. To ensure accountability for new hires, the Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (Attachment #10 - Employee Tracking Chart) This will be completed by 4/1/19. The CEO will retrain all staff on this regulation by 4/1/19.(Attachment #4 -Staff Signed 6400 Trainings) By 5/30/19 the CEO will review that these action steps were completed and applied to any new hires. |
04/01/2019
| Implemented |
| 6400.161(a) | During the onsite inspection completed at the residential home on 2/15/19, all of Individual #2's medications they take on a daily basis was taken from their original containers/packaging and stored in a week-long pill container. The individual was suspected to visit with family overnight from Friday evening until Sunday evening. The medications the individual takes during that time frame, were the medications that were removed from their original container. | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | It is the responsibility of the medication administration staff to keep all medications in their original containers. The Program Specialist has contacted the pharmacy that Individual #2 uses and has requested special containers/packaging for the medications that the Individual takes to her family¿s with her on the weekends with separate blister packs from those blister packs needed during the week when Individual #2 resides at Creekside. The containers/packaging includes pharmacy labels. This was completed 2/21/19. All staff will be trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) The CEO will give oversight to the implementation of these steps by 5/30/19 |
04/01/2019
| Implemented |
| 6400.163(c) | -The following psychiatric medication reviews for Individual #2 did not include the reason for prescribing the medications or the need to continue the prescribed medications: 2/4/19, 11/5/18, 8/13/18.
-Individual #1's psychiatric medication reviews also did not include the reason for prescribing the medication or the need to continue the medications. The individual is prescribed medications for Anxiety/Agitation and Mood Disorder. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Program Specialist is responsible for the accuracy of the quarterly med review/form. The Program Specialist will be amended the Quarterly Medication Review form used for all Individuals served by Bethel Care by 3/5/19. The amendment will include the reason for prescribing the medication and the need to continue the medications. This form will be implemented immediately. All Bethel Care Staff will be trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) The CEO will review 10% of the Program Specialist¿s work product concerning these steps of corrective action. This will be done by 5/31/19 |
04/01/2019
| Implemented |
| 6400.164(a) | Individual #2 is prescribed Protonix Dr 40mg, take 1 tablet by mouth 1 time daily. Per residential staff, Staff #3, Individual #2's doctor requests that the medication be administered at 6:30am, prior to administration of all other 8am medications. Per Staff #3, the medication is being administered at 6:30am. The medication administration log indicates that Protonix DR 40mg is being administered at 8am daily. The medication log does not indicate the correct time of administration.
-During the onsite inspection on 2/15/19, Individual #2's medication log was already initialed "A", defined as "away", for the evening of 2/15/19-2/17/19 prior to the individual going away for the weekend. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | It is the responsibility of the certified medication administration staffing to administer the medications to the Individual as prescribed. The house manager will immediately change the MAR to reflect the correct time of the dosage of Protonix as it is being administered at 6:30 and the MAR states the administration time of 8am. (Attachment #8 -Corrected MAR), All Bethel Care staff will be re-trained not to mark anything on a MAR prior to the actual date. All medication administration staff will be re-trained on this regulation by 4/1/2019. (Attachment #4 -Staff Signed 6400 Trainings) |
04/01/2019
| Implemented |
| 6400.167(b) | Per residential staff, Individual #2's psychiatrist gives verbal orders to hold medications multiple times during the month if the individual is displaying certain behaviors. According to Individual #2's medication logs, medications have been omitted multiple times since their date of admission on 8/19/18. There was no record of a written doctor's order to hold and not administer any medications for Individual #2. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | It is the responsibility of the residential staff who are certified to administer medications, to administer medications as stated on the label or a doctor¿s written order. The Program Specialist will obtain written orders from Individual #2¿s doctor who gave the verbal order to hold and not administer medications for Individual #2. Bethel Care staff will be re-trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) As a corrective action step the Program Specialist will review all physician communication logs for both individuals and make a report to CEO of this correspondence every Quarter. (Attachment #7 - Quarterly Review of Physician Communication Logs) This action step will be completed by 5/30/19. The CEO will give oversight that retrainings have occurred and will review the report as part of this corrective action plan by 5/30/19 |
04/01/2019
| Implemented |
| 6400.181(e)(9) | Individual #1's 7/27/18 assessment doesn't include all of the individual's diagnosis. The assessment was missing: Type 2 Diabetes, Bilateral Myopia, Vitreous Degeneration of the left eye, Morbid Obesity, Depression, past surgeries of deviated septum adenoidectomy and polypectomy, Hyperglyceridemia, triglycerides raised, Obstructive Sleep Apnea, Anemia, eating disorder, irregular periods, allergic rhinitis, Autism Spectrum Disorder, Oppositional Defiant Disorder, Diabetes Mellitus and severely obese. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | It is the responsibility of the program specialist to ensure that the assessment is complete and void of errors or omissions of the diagnosis of the Individual. The assessment was missing: Type 2 Diabetes, Bilateral Myopia, Vitreous Degeneration of the left eye, Morbid Obesity, Depression, past surgeries of deviated septum adenoidectomy and polypectomy, Hyperglyceridemia, triglycerides raised, Obstructive Sleep Apnea, Anemia, eating disorder, irregular periods, allergic rhinitis, Autism Spectrum Disorder, Oppositional Defiant Disorder, Diabetes Mellitus and severely obese. The program specialist will immediately revise the assessment. This corrective action will be completed 3/5/19. (Attachment #5 - Assessment) The Program Specialist and all Bethel Care staff will be re-trained by the CEO by 4/1/19 on this regulation (Attachment #4 -Staff Signed 6400 Trainings). Bethel Care¿s CEO will give oversight of the implementation of these corrective actions. This corrective action step will be completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.181(e)(12) | Individual #1's 7/27/18 assessment did not include recommendations for specific areas of training, programming and services. Field was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | It is the responsibility of the Program Specialist to create an accurate assessment of the Individual. Individual #1¿s assessment did not include recommendations for specific areas of training, programming and services. The field was left blank. The Program Specialist will correct the assessment by filling in the field ¿recommendations for specific areas of training, programming and services¿ by 3/5/19. (Attachment #5) The Program Specialist and all Bethel Care Staff will be re-trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings). The CEO will give oversight that these corrective action plans will be implemented and include the review of this regulation in the Program Specialist¿s Annual Training. (Attachment #6 - P.S. Annual Training) This will be done by 5/30/19. |
04/01/2019
| Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan (ISP) didn't include a protocol to address the social, emotional and environmental needs of the individual that included all psychiatric diagnoses'. The individual's current protocol addresses ADHD, Bipolar and Mood disorder. However the individual's record also includes additional diagnoses of Depression and Oppositional Defiant behavior. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | It is the responsibility of the Program Specialist to ensure that the ISP includes a protocol to address the social, emotional and environmental needs of the individual that includes all psychiatric diagnoses'. The SEEN plan did not include the additional diagnoses of depression and oppositional defiant disorder.
First, the Program Specialist will create an addendum to the assessment adding the psychiatric diagnosis of oppositional defiant disorder and the SEEN plan protocol, and will send it to Individual #1¿s team. (Attachment #1 - Addendum to Assessment) Secondly, the Program Specialist will send a request via track changes to the SC to correct the ISP. (Attachment #2 - Track Changes) The Program Specialist will review Individual #2¿s ISP for discrepancies as well. (Attachment #3 - Track Change Monitoring Form) This will be completed by 3/5/2019. Thirdly, all Bethel Care staff will be re-trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) Fourthly, Bethel¿s CEO will review the implementation of Steps 1, 2, and 3 by 5/30/19. |
04/01/2019
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include their potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | Accuracy of the ISP is the responsibility of the Program Specialist. Individual #1¿s ISP did not include his/her potential to advance in vocational programming. The Program Specialist will include vocational programming on the addendum to the assessment noted in 213(11) and will send the addendum to Individual #1¿s entire team by 3/5/19. (Attachment #1 - Addendum to Assessment) The Program Specialist will also send a request to the SC via track change by 3/5/19 (Attachment #2 - Track Changes) The Program Specialist along with the entire Bethel Care staff will be re-trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) Bethel Care¿s CEO will give oversight of the implementation. This corrective action step will be completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.183(7)(iv) | Individual #1's Individual Support Plan (ISP) did not include their potential to advance in competitive community-integrated employment. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment.
| It is the Program Specialist¿s responsibility to ensure accuracy of the ISP. Individual #1¿s ISP did not include their potential to advance in competitive community-integrated employment. The Program Specialist will include the assessment of the individual¿s potential to advance in Competitive community-integrated employment on the addendum to the assessment noted in 213(11) and will send the addendum to Individual #1¿s entire team by 3/5/19.(Attachment #1 - Addendum to Assessment) The Program Specialist will also send a request to the SC via track change by 3/5/19 (Attachment #2 - Track Changes) The Program Specialist along with the entire Bethel Care staff will be re-trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) Bethel Care¿s CEO will give oversight of the implementation of these corrective actions. This corrective action step will be completed by 5/30/19. |
04/01/2019
| Implemented |
| 6400.213(11) | Individual #1's 7/11/18 physical examination form indicated under the allergy section: "nkda." The individual's 2017 physical lists "nkda, dogs, dust, mold and grass" under the allergy section. The individual's Individual Support Plan (ISP) indicated the individual had allergies to "dogs/dust/pollen." The individual's 6/29/18 medication review appointment form indicated allergies to Trileptal. The allergies are not the same in all the documents.
-As referenced in 6400.141(c)1 and 6400.181(e)(9), Individual #1's current diagnosis that are listed on their 2018 and 2017 physicals, their 2018 assessment and in the ISP do not match. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | It is the responsibility of the Program Specialist to monitor the ISP for content discrepancies. The allergies are not the same in all the documents in Individual #1¿s record.
Individual #1's current diagnoses which are listed on the 2018 and 2017 physicals, the 2018 assessment, and in the ISP do not match. First, the Program Specialist will immediately write an addendum to Individual #1¿s assessment correcting the allergy section and send it to Individual #1¿s team by 3/5/19. (Attachment #1 - Addendum to Assessment) Secondly, the Program Specialist will complete a request via track change to the SC so that all documentation in Individual 1#¿s record is uniform by 3/5/19. (Attachment #2 - Track Changes) Thirdly, as a quality measure and to prevent future occurrences, the Program Specialist will review all track changes of both individuals on a monthly basis to ensure that their ISPs are properly updated at all times. (Attachment #3 - Track Change Monitoring Form). Fourthly, all Bethel Care staff will be trained on this regulation by 4/1/19. (Attachment #4 -Staff Signed 6400 Trainings) Fifthly, Bethel Care¿s CEO will oversee the implementation of these four Corrective Action steps by 4/1/19. Sixthly, Bethel Care¿s CEO will give oversight of the implementation of Step #3 by quarterly reviewing 10% of the Program Specialist¿s work product as described in Step #3. This corrective action step will be completed by 5/30/19. |
04/01/2019
| Implemented |
| Article X.1007 | Staff #1's date of hire was 5/21/18 and her criminal history check was completed on 5/25/18; after employment. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Staff #1's date of hire was 5/21/18 and her criminal history check was completed after employment on 5/25/18. The Program Specialist will create an employee tracking chart that will include: Employee¿s name; Background check date; Physical Date; TB test; Orientation training date of completion; and other mandatory trainings (ie. CPR, First Aid). (Attachment #10) The CEO will retrain all staff of this regulation. (Attachment #4) These steps will be completed by 4/1/19. The CEO will oversee the implementation of this step by 5/30/19. |
04/01/2019
| Implemented |