Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room. | 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.
| The label was removed from the old phone and placed on the new phone. The Program Manager will use the Physical Site Monitoring Tool for weekly inspections of the home to ensure all emergency telephone numbers are on the telephone. [At least monthly for 1 year and continuing at least quarterly thereafter, the CEO or designee shall audit a 25% sample of weekly checklist to ensure completion and review and revise as needed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
10/25/2019
| Implemented |
6400.82(e) | The bathtub located in the main bathroom of the home did not have a nonslip surface or mat. | Bathtubs and showers shall have a nonslip surface or mat. | A new bath mat was purchased and placed in the tub. The Program Manager will use the Physical Site Monitoring Tool when completing weekly site inspections to ensure the bath mat is in the tub. Should an individual refuse to use the bath mat, he/she will be given a waiver to sign.[Nonskid surface was placed in the bathtub the day of the inspection. Documentation of the weekly site inspections to include that bathtubs and showers shall have a nonslip surface shall be kept. At least monthly for 1 year and continuing at least quarterly thereafter, the CEO or designee shall audit a 25% sample of weekly checklist to ensure completion and review and revise as needed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
10/25/2019
| Implemented |
6400.141(a) | Individual #2, date of admission 5/1/19, did not have a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual is scheduled for his annual physical on 11/22/19 with Shelly Somers which will be documented on the new physical form that meets all chapter regulations. Manager of Operations will complete monthly audits of individual records to ensure compliance. [Individual #2 had a physical examination signed by the physician on 11/22/19. Immediately and upon completion the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included, missing information shall be obtained immediately. Documentation of audits shall be kept. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals have physical examinations completed, timely. (DPOC by AES,HSLS on 12/6/19)] |
11/15/2019
| Implemented |
6400.181(a) | Individual #1's assessment was most recently completed on 5/14/18. | 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 annual assessment has been completed for individual #1 on 10/28/19.
Program Specialist will complete the assessment no later than 60 days after individual's admission date. The Program Specialist will review the assessment bi-annually, and update the assessment annually thereafter. [Immediately and upon competition for at least one year, the CEO shall audit all individuals' current assessments to ensure completion, timely, with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
10/28/2019
| Implemented |
6400.15(b) | The agency completed a self-assessment on a Self Inspection/Declaration Tool, a document used for opening new homes. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The self assessment was redone on the correct tool; the Department's licensing inspection instrument. The Program Manager will complete self assessments 3-6 months prior to expiration of certificate on the Department's licensing inspection tool. The Director will review the tool and sign off after each inspection. [Prior to completion of the self-assessment, the CEO or designee shall locate the most recent self-assessment tool on the Departments web site to ensure the correct self-assessment is completed. Immediately and upon completion, the CEO or designee shall audit all self-inspection completed for each home to ensure all regulations are addressed and all information is completed and there are not any areas left blank. (DPOC by AES,HSLS on 12/6/19)] |
11/08/2019
| Implemented |
6400.32(i) | The agency is locking "snack" food in a cabinet in the kitchen of the home. The individuals do not have access to the keys to the locked cabinet. | An individual has the right of access to and security of the individual's possessions. | All food was removed from the locked pantry. Each individual put their snacks in their own room. On the Physical Site monitoring tool, another bullet has been added which reads: the home is free of locked food. The Program Manager will continue to utilize this tool when completing weekly house inspections. [Within 30 days of receipt of the plan of correction, upon hire and continuing at least annually, the CEO or designee or outside source shall educate all staff persons on all individual rights as per 6400.31a-34b. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/6/2019)] |
11/07/2019
| Implemented |
6400.165(g) | Individual #2 had a review of medication prescribed to treat symptoms of psychiatric illness on 5/13/19 and then again on 9/25/19. [Repeat Violation-11/19/18- regulation 163(c)] | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A Monitoring Tool has been created to mange when quarterly reviews are needed. The Manager of Operations will be responsible for overseeing this tracking tool and ensuring the Quarterly Psych-Med Reviews are being completed on time. Should an individual not attend his/her appointment in which the Med-Review is to be completed, the Manager of Operations will submit a request via fax to the prescribing doctor to ensure the Quarterly Med-Review is completed on time. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking document and all individuals' medication reviews to ensure timely completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/11/2019
| Implemented |
6400.181(f) | The program specialist did not provide Individual #2's assessment completed on 5/9/19 to the plan team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The assessment completed on 5/9/19 has been provided to the team members. The Program Coordinator will request the assessment from the Program Specialist at least 30 days prior to the individual plan meeting to disperse to the team.[Documentation of the correspondence showing the program specialist provide the assessments to the individuals' plan team members shall be kept and available upon request by the Department. Immediately, the CEO shall educate the program specialist of the responsibilities of the program specialist position including providing assessments to individual plan team members at least 30 calendar days prior to then individuals' plan team meetings. Documentation of the training shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/11/2019
| Implemented |
6400.186 | Individual #2's ISP last updated 9/3/19 states Individual #2 "NEEDS ASSISTANCE AND SUPERVISION WHEN USING THE STOVE OR OVEN". Individual #2's assessment completed 5/9/19 states "knowledgeable of danger of heat sources." Individual #2's ISP, last updated 9/3/19 reports Individual #2 "KNOWS HOW TO USE CLEANER APPROPRIATELY. HE WOULD NEED SOME SUPERVISION WHEN UPSET AS HE COULD THEN TRY TO USE IT IN AN INAPPROPRIATE MANNER." Individual #2's assessment completed 5/9/19 states "should not use poisonous materials. Can use cleaning products with supervision." Individual #2's ISP, last updated 9/3/19 reports Individual #2 "REGULATES HIS OWN BATH WATER AND SHOWERS INDEPENDENTLY. [Individual #2] DOES NOT KNOW HOW TO SWIM AND WILL ONLY STAY IN WATER WHERE HE IS ABLE TO TOUCH THE BOTTOM". Individual #2's assessment completed 5/9/19 states "likes swimming, but needs supervision." Individual #2's ISP last updated 9/3/19 states "WOULD NEED PROMPTING AND MAYBE ASSISTANCE TO EXIT QUICKLY". Individual #2's assessment completed 5/9/19 states "quickly evacuates." | The home shall implement the individual plan, including revisions. | Program Specialist has requested a team meeting to address changes/progress to individual's ISP. Program Specialist will continue to complete assessment with individual as required. Program Specialist will request team meeting 60-90 days after individuals admission date to revise ISP. [Immediately, upon revisions and continuing at least quarterly, the Program specialist shall audit all individuals' current assessments and current ISP to ensure consistency and accuracy that reflects the individuals' needs. The program specialist shall coordinate development of the ISP including the revisions with the individuals and the plan team members. Immediately and upon hire, the CEO shall educate the program specialist of the responsibilities of the program specialist position including providing assessments to individual plan team members at least 30 calendar days prior to then individuals' plan team meetings. Documentation of the training shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/15/2019
| Implemented |
6400.213(7) | The record for Individual #1 did not include an invitation and signature page from annual ISP meetings. The record for Individual #2 did not include an invitation and signature page from annual ISP meetings. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | The invitation and signature page has been put in both individual's records. A Monitoring Tool has been created which has a list of content required in each individual's file. The Manager of Operations will utilize this tool when completing weekly audits of the individual records. [Documentation of the monthly audits shall be kept. Immediately, the CEO shall educate the program specialist and the manager of operations to ensure all required information is included in all individuals' records. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/08/2019
| Implemented |