| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not completed 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.
| A self assessment of the home was completed on 10/28/19.
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.[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)] |
10/28/2019
| Implemented |
| 6400.141(a) | Individual #1, date of admission 7/31/18, had a physical examination completed on 3/29/19. Individual #2, date of admission 3/15/19, did not have a physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | THRIVE has created a physical form that meets chapter requirements. A physical form has been faxed to individual #2 doctor who will transfer information from individuals most recent physical (3/13/19). Manager of Operations will utilize monitoring tool when completing monthly audits of individual records. [Individual #2 had a physical examination signed by the physician on 11/25/19. 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 |
| 6400.141(c)(6) | Individual #1, date of admission 7/31/18, had a Tuberculin skin testing completed 3/27/19 [Repeat violation-11/19/18] | 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. | Program specialist will utilize a checklist of all admission requirements prior to admission. A new physical form that meets all chapter regulations has been created by THRIVE. Manager of Operations will complete monthly audits of individual records to ensure compliance. [Documentation of the monthly audits shall be kept. Immediately, the CEO shall educate the program specialist and the manager of operations of their responsibilities to ensure timely completion of all individuals' physical examinations including Tuberculin testing. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/15/2019
| Implemented |
| 6400.141(c)(7) | Individual #2, date of birth 2/7/96 has not had a gynecological examination for including a breast examination and a Pap test. Individual #2 was admitted on 3/15/19. | 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. | Individual #2 has been scheduled for a gynecological examination for 12/20/19. THRIVE now has a physical/medical form that meets chapter regulations. A monitoring tool has been created and the Manager of Operations will audit individual records monthly to ensure all records are current. [Individual #2 was seen in the gynecologist office 2/26/2019 with follow up to return for annual examination. Immediately and upon completion the CEO or designee shall audit all individuals' current physical examinations to ensure all required additional examinations are completed. 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 |
| 6400.143(a) | Individual #1, date of birth 10/12/72, refuses to have annual gynological examinations. The refusal and continued attempts to train the individual about the need for health care were not documented in the Individual's record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A refusal form has been created for use if an individual refuses medical treatment. This form will include name/date, type of appointment the individual is refusing and why, as well as the counsel offered to the individual. This form will be kept in the individual's records. [A Doctor visit refusal form was completed on 11/11/9 for Individual #1. Immediately, the CEO shall develop and implement policies and procedures for individuals' refusals of medical and dental examinations or treatments to ensure the health and safety of all individuals. Documentation of the aforementioned policies and procedures shall be kept and all staff person shall be educated on the aforementioned policies and procedures with in month of completion. (DPOC by AES,HSLS on 12/6/19)] |
10/29/2019
| Implemented |
| 6400.181(a) | Individual #1, date of admission 7/31/18 had an initial assessment completed on 7/28/18. | 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 |
| 6400.165(g) | Individual #1 had review of medication prescribed to treat symptoms of psychiatric illness on 12/7/18 and then again on 3/27/19. Individual #2, date of admission 3/15/19 had an initial review of medication prescribed to treat symptoms of psychiatric illness 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. | Individual #1 had review of medication on 9/25/19, 6/27/19, and 3/27/19. Individual #2 will have her next medication review by 12/25/19. A medication review tracking form has been created to monitor when psych med reviews are due. The Program Coordinator will schedule appointments for med review as needed. [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)] |
11/15/2019
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #2's assessment, completed 3/18/19 to the individual 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 3/18/19 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 |
| 6400.213(7) | The record for Individual #1, date of admission 7/31/18 did not include invitations and signature pages from annual ISP meetings. The record for Individual #2, date of admission 3/15/19 did not include invitations and signature pages from annual ISP meetings. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | Program Specialist requested invitation and signature page from SC on 11/08/19. Program Specialist requested invitation and signature page from individual #2 SC on 11/15/19. Manager of Operations will complete monthly audits of individual records to ensure all required documents are present in each record. [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)] |
11/15/2019
| Implemented |