| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is not a source of light in Individual #2's bedroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance replaced a lightbulb for individual #2's bedroom. Maintenace will review the physical site of the self-assessment tool weekly. These weekly checks will be reviewed monthly with supervisors unless immediate attention is required. |
04/24/2023
| Not Implemented |
| 6400.68(b) | At 11:22AM on 3/29/2023, the hot water temperature measured 136°F at the bathtub in the bathroom along the hallway. [Repeat Violation, 4/18/2022] | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water heater dial has been adjusted so that the water temperature will fall within (110° -119° ) 6400 regulation guidelines. Anti-scald devices are being installed on each faucet to prevent temperatures of 120° and above. |
04/17/2023
| Not Implemented |
| 6400.83(c) | At 11:17AM on 3/29/2023, a ceramic plate with food was sitting inside the microwave. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | Residential supervisors will review agency policy, guidelines and practices on utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. This will be done through document reviews and interviews with staff. Staff will sign off that this initial review occurred. |
04/24/2023
| Not Implemented |
| 6400.101 | There is a chain lock on the front door of the home, posing an obstructed egress when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| TFS Maintenance removed the chain lock on front door on 4/5/23. |
04/17/2023
| Implemented |
| 6400.104 | On 9/2/2022, the agency sent a notification letter to the local fire department to inform them of the individual's needs and the home's layout. The letter incorrectly states that the two-bedroom home has one bedroom. An updated letter was not sent when a second individual moved into the home on 12/20/2022. | 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 letter to the Stonecliffe Fire Department was updated as a 2-bedroom apartment and resent out on 4/4/23. |
04/17/2023
| Implemented |
| 6400.107 | At 11:25AM on 3/29/2023, a space heater was on the floor next to the bed in Individual #2's bedroom. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The portable heater was removed from the residence on 3/29/23. The consumer brought the space heater into the home without the staff¿s knowledge or supervisors¿ permission. |
04/24/2023
| Not Implemented |
| 6400.112(a) | An unannounced monthly fire drill was not held in September 2022. | An unannounced fire drill shall be held at least once a month. | Individual #2 was respite for the month of September 2022. TFS was unaware that a fire drill was needed for a respite client. TFS policy will be updated stating that any licensed residential must have fire drills. All respite clients must have fire safety training and drill upon admission. |
04/24/2023
| Not Implemented |
| 6400.112(c) | The written fire drill records for the fire drills held from 10/12/2022 through 2/22/2023 do not include the exit route used. | 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. | Staff will be retrained on fire drill/safety documentation to state 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. TFS fire safety log was updated to cover all necessary areas. A copy of the revised fire safety log document will be emailed to licensing for review. |
04/24/2023
| Not Implemented |
| 6400.113(a) | Individual #2, date of admission, 9/4/2022 was initially instructed in fire safety on 10/11/2022. | 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 #2 was respite on 9/4/22. TFS was unaware that a fire training was needed for a respite client. TFS supervisors will be retrained on the TFS policy stating that any respite/residential clients must have fire safety training, annual training 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. This must be completed upon admission and not after admission date. Documentation of training will be on record. |
04/24/2023
| Not Implemented |
| 6400.114(b) | At 11:24AM on 3/29/2023, there were cigar ashes on the window sill and dresser in Individual #2's bedroom. The agency's smoking policy, dated 12/13/2019, smoking in the homes is prohibited. | Written smoking safety procedures shall be followed. | TFS consumer smoking safety procedures policy was updated. This form will be reviewed with individual #2 and signed as receipt of understanding. |
04/24/2023
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, completed 12/19/2022, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination, completed 9/13/2022, does 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. | Staff will be retrained on the physical examination form understanding that all information is required to be filled out by medical personnel including medical information pertinent to diagnosis and treatment in case of an emergency . Documentation will be on record. |
04/24/2023
| Implemented |
| 6400.151(a) | Direct Service Worker #2, date of hire 10/25/2022, had an initial physical examination completed on 2/15/2023. | 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. | When administration spoke with TFS Direct Support worker #2 about her physical being out of compliance, she handed in another physical examination form that was completed prior to her being hired at TFS. This physical examination form is in compliance because it is before her hire date, but not more than 12 months prior. Documentation is on record. |
04/24/2023
| Implemented |
| 6400.171 | At 11:18AM on 3/29/2023, a carton of eggs with a best by date of 2/24/2023 was in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Residential supervisors will review agency policy, guidelines and practices for food safety through document reviews and interviews with staff. Staff will sign off that this initial review occurred. |
04/24/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's assessment, completed 1/19/2023, does not include the individual's functionals strengths, needs and preferences. Individual #2's assessment, completed 10/5/2022, does not include the individual's functionals strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.181(e)(2) | Individual #1's assessment, completed 1/19/2023, does not include the individual's likes, dislikes and interests. Individual #2's assessment, completed 10/5/2022, does not include the individual's likes, dislikes and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.181(e)(9) | Individual #1's assessment, completed 1/19/2023, does not include the individual's disability including functional and medical limitations. Individual #2's assessment, completed 10/5/2022, does not include the individual's disability including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.181(e)(10) | Individual #1's assessment, completed 1/19/2023, does not include the individual's lifetime medical history. Individual #2's assessment, completed 10/5/2022, does not include the individual's lifetime medical history. lifetime medical history. | The assessment must include the following information: A lifetime medical history. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.181(e)(11) | Individual #2's assessment, completed 10/5/2022, does not include the individual's psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.181(e)(12) | Individual #1's assessment, completed 1/19/2023, does not include recommendations for specific areas of training, programming and services. Individual #2's assessment, completed 10/5/2022, does not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | TFS Annual Assessment updated and restructured to better track and find demographic information for the consumers. The program will be retrained on the restructured form. |
04/24/2023
| Not Implemented |
| 6400.34(a) | Individual #1 was informed and explained his Individual Rights on 1/7/2023. These rights did not include 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. Individual #2 was informed and explained his Individual Rights on 10/5/2022. These rights did not include 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The TFS Rights review and client signature sheets were updated to include: 6400.32f, an individual has the right to refuse to participate in activities and services; 6400.32g, an individual has the right to control the individual's own schedule and activities; and 6400.32v, an individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. |
04/24/2023
| Implemented |
| 6400.46(a) | Direct Service Worker #1 was hired on 9/27/2022 and was trained in Fire Safety on 12/16/2022. Direct Worker #2 was hired on 10/25/2022 and was trained in Fire Safety on 12/18/2022. | 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. | Supervisors will be retrained on Fire Safety requirements and regulations for newly hired employees. Supervisors will understand that program specialists and direct service workers shall be trained before working with individuals. |
04/24/2023
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the name of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Not Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the strength of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Not Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the dosage form of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The TFS compliance supervisor, who is med trained, will review the MARS weekly for 3 months. If there are not any errors or discrepancies found, the compliance supervisor will decrease reviews to once a month and will continue until further notice of positive compliance in entirety. In the front of the MARS there will be a mock MAR for demonstration and an employee check off list that includes the individual specific time reminder for medication administration. |
04/24/2023
| Not Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the dose of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Not Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the route of administration of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The TFS compliance supervisor, who is med trained, will review the MARS weekly for 3 months. If there are not any errors or discrepancies found, the compliance supervisor will decrease reviews to once a month and will continue until further notice of positive compliance in entirety. In the front of the MARS there will be a mock MAR for demonstration and an employee check off list that includes the individual specific time reminder for medication administration. |
04/24/2023
| Not Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the frequency of administration of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the administration times of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Not Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Diclofenac with instructions to, "apply 2GM topically four times a day for pain. The following over-the-counter medications were Individual #1's medication box: Potassium, Vitamin D3, Midol Complete, Allergy Relief, Robitussin and No Drip Nasal Spray. The individual's March 2023 Medication Administration Record did not include the diagnosis or purpose of the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Stonecliffe supervisor completed the original March MAR that included errors and missing components. TFS administration gave residential supervisor a write-up for unsatisfactory documentation on the MAR. TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. The supervisor of Stonecliffe will be retrained on 4/20/2023. |
04/24/2023
| Not Implemented |
| 6400.166(a)(13) | Individual #1's prescribed medication, Metformin, was not initialed as administered on 3/28/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | TFS certified medication trainer will be re-training the Stonecliffe supervisor as well as all the staff. The staff will be retrained on 4/13/2023. |
04/24/2023
| Not Implemented |
| 6400.182(c) | Individual #2's assessment, completed 10/5/2022, states that he can have 16 hours of unsupervised time in the home and 24 hours of unsupervised time in the community. Individual #2's Individual Plan, completed 2/23/2023 states that the, "[Individual #2] NEEDS TO BE SUPERVISED AT ALL TIMES" and Individual #2 needs 24 hours supervision in the home and "CAN BE LEFT ALONE IN COMMUNITY FOR 30 MINUTES." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | TFS program specialist will re-update Individual #2's assessment to reflect the current ISP documentation. Also notating that a meeting between TFS officials and Individual #2's treatment team is being scheduled to discuss observations, assessments, and potential updates to his service plan. |
04/24/2023
| Not Implemented |
| 6400.195(a) | The knives and sharp objects in the home are locked in a closet due to concerns with Individual #1. Individual #1 does not have a restrictive procedure. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Individual #1 is starting behavioral services. They will begin assessing, observing, and gathering data. This will be utilized for goal planning and an introduction for a possible restrictive procedure plan. The knives and sharp objects in the home were removed from the locked closet. They were placed back into the kitchen drawer. |
04/24/2023
| Not Implemented |
| 6400.213(1)(i) | Individual #1's record does not include identifying marks. This section was left blank. Individual #2's record does not include identifying marks. This section states, "unknown." | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | TFS supervisors will be retrained on completing the Individual's face sheet including identifying information such as personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. |
04/24/2023
| Implemented |