| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 3/18/18. The agency's certificate of compliance has an expiration date of 6/9/18. In addition, compliance was not measured for regulations 62(a), 62(b), 151(a) through 152(c), 181(e)(10) through 181(f), 189(a) through 189(c), 213(1)(iv) and 213(1)(vi). [Repeat violation 7/20/17 et al.] | 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 areas of this self-assessment that were not completed were completed on 7/13/2018 and the document was sent to Nancy Armstrong via email. The self-assessment of programs policy was updated on 7/10/2018 to align with the correct expiration date of the license instead of the licensing visit date. The policy was also updated to include that the program manager will review the documents and work with the site supervisors and administrative assistant to ensure all areas are reviewed. The management team will be trained on the new policy by 8/19/2018.[Documentation of trainings and reviews shall be kept. (AS 7/20/18)] |
08/19/2018
| Implemented |
| 6400.46(g) | Direct Service Worker #1 completed fire safety training on 3/10/17 and then again on 5/18/18. [Repeat violation 7/20/17 et. al.] | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | The site supervisors and program managers will be re-trained on fire safety requirements by 8/1/2018. Specifically, we will review the following areas:
1. You must have a drill every month
2. The drill must be documented on the updated current form
3. If it takes more than 2 ½ minutes to evacuate you must repeat the drill within 24 hours
4. You must vary the location of the fire
5. You must vary the evacuation route (you can¿t always use the same exit)
6. You must vary the day of week and time of day
7. You must list the time of the drill both minutes and seconds ¿ if it is 2 minutes even put 0 seconds
8. Overnight drills (October & April) must take place between 12:00 midnight and 6 am.
9. If staff do not receive the fire safety training by their annual due date they will be removed from the schedule.
All fire drill forms are to be submitted to the department administrative assistant by the 15th of the month. The administrative assistant is responsible for reviewing the drills to make sure they are compliant. If they are not compliant they will be returned to the site supervisor and the drill will be re-done. The department training curriculum is revised annually (in July) so that all employees will receive the fire safety training every 11 months. All supervisors and program managers were re-trained on this policy in July, 2018. [Within 15 days of receipt of the plan of correction, the CEO or designee shall develop and implement a tracking system to ensure timely completion of fire safety training for program specialists and direct service workers and train staff person responsible for monitoring fire safety training of the aforementioned tracking system. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas. Documentation of audits shall be kept. (AS 7/20/18)] |
07/27/2018
| Implemented |
| 6400.163(c) | Individual #1 had a psychiatric medication review completed on 9/15/17 and then again on 12/27/17. [Repeat violation 7/20/17 et.al.] | 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. | A standard operating procedure has been developed for tracking and monitoring all medical appointments including psychiatric medication reviews. The current medical appointments have been loaded into a chart which the program manager will sort by ¿next due¿ and review with each site supervisor at the beginning of each month. The supervisors will be responsible to provide copies of appointment documentation of each required appointment to the program manager. Once the documentation is received the program manager will review the appointment summary to make sure it is appropriately filled out. If the form is complete the program manager will update the medical appointment chart to maintain current information and send the copy of the appointment summary to the program specialist. The program manager was trained on this process on 7/18/18. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 10% sample of Psychiatric medication reviews to ensure timely completion with required information and to ensure individuals are administered medication as prescribed. (AS 7/20/18)] |
07/18/2018
| Implemented |
| 6400.186(b) | Individual #1 did not sign and date the ISP reviews end-dated 9/26/17 and 12/30/17. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | This review was completed by a program specialist / site supervisor who is no longer in that position. TCV has hired a dedicated program specialist who has been trained on the regulatory requirements to ensure compliance. The ISP three month reviews policy was reviewed with the current program specialist to ensure proper understanding of the policy on July 17, 2018. The current policy is for the program specialist to complete the three month review within 5 days of the end of the review period. The form is to be reviewed with the individual or their guardian within 15 days of the end of the review period and distributed to all appropriate team members within 30 days of the end of the review period. By the fifth of each month the program specialist is to provide the program manager with a checklist of the three month reviews that were completed and the program manager is to review 10% of all completed reviews. If a consumer is unavailable or chooses not to sign the review the program specialist will document the reason and all attempts to obtain the signature on the review form.
The 9/26/17 and 12/30/17 ISP reviews were signed by Individual #1 on 7/10/2018. |
07/17/2018
| Implemented |