nc dhsr mhlcs: plan of correction...2019/03/27 · observation, the facility management failed to...

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 03/14/2019 FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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Division of Health Service Regulation

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NAME OF PROVIDER OR SUPPLIER

I INNOVATIONS, INC - 2071 HERITAGE WAY

STREET ADDRESS, CITY, STATE, ZIP CODE

2071 HERITAGE WAY

CAMERON, NC 28326

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

V 000 INITIAL COMMENTS V 000

A complaint and follow-up survey was completed on March 4, 2019. The complaint was substantiated (Intake #NC00148024). Deficiencies were cited. This facility is licensed for the following service category: 10A NCAC 27G. 5600C Supervised Living for Adults with Developmental Disabilities

V 108 27G .0202 (F-I) Personnel Requirements

10A NCAC 27G .0202 PERSONNEL REQUIREMENTS(f) Continuing education shall be documented.(g) Employee training programs shall be provided and, at a minimum, shall consist of the following:(1) general organizational orientation;(2) training on client rights and confidentiality as delineated in 10A NCAC 27C, 27D, 27E, 27F and 10A NCAC 26B;(3) training to meet the mh/dd/sa needs of the client as specified in the treatment/habilitation plan; and(4) training in infectious diseases and bloodborne pathogens.(h) Except as permitted under 10a NCAC 27G .5602(b) of this Subchapter, at least one staff member shall be available in the facility at all times when a client is present. That staff member shall be trained in basic first aid including seizure management, currently trained to provide cardiopulmonary resuscitation and trained in the Heimlich maneuver or other first aid techniques such as those provided by Red Cross, the American Heart Association or their equivalence for relieving airway obstruction.(i) The governing body shall develop and

V 108

Division of Health Service RegulationLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

If continuation sheet 1 of 206899STATE FORM BNWK11

CEO, President

Please see attached:

I Innovations, Inc's -Responseto all of the POC deficiencies.

03/24/19

on-goingmonitoring

srmcmickleReceived

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V 108Continued From page 1 V 108

implement policies and procedures for identifying, reporting, investigating and controlling infectious and communicable diseases of personnel and clients.

This Rule is not met as evidenced by:Based on record reviews and interviews, the facility management failed to document required training was provided to 1 of 3 (#1) current audited staff and 1 of 2 audited (FS #4) former staff. The findings are:

Review on 2/7/19 of Staff #1's personnel record revealed:- an "Independent Contract Agreement" signed 11/12/18 documenting employment as a paraprofessional staff to provided direct care to clients.- no documentation the staff received any of the required training prior to or during employment

Review on 2/7/19 of FS #4's personnel record revealed:- no documentation of a hire date.- documentation in client records of services provided through January 2019.- no documentation the staff received any of the required training prior to or during employment

Interview on 2/8/19 with the Qualified Professional (QP) confirmed:- Staff #1 and FS #4's records did not contain documentation of completed trainings. The staff were employed prior to her taking the position as QP.



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V 110 27G .0204 Training/Supervision Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND SUPERVISION OF PARAPROFESSIONALS(a) There shall be no privileging requirements for paraprofessionals.(b) Paraprofessionals shall be supervised by an associate professional or by a qualified professional as specified in Rule .0104 of this Subchapter. (c) Paraprofessionals shall demonstrate knowledge, skills and abilities required by the population served. (d) At such time as a competency-based employment system is established by rulemaking, then qualified professionals and associate professionals shall demonstrate competence.(e) Competence shall be demonstrated by exhibiting core skills including:(1) technical knowledge;(2) cultural awareness;(3) analytical skills;(4) decision-making;(5) interpersonal skills;(6) communication skills; and(7) clinical skills.(f) The governing body for each facility shall develop and implement policies and procedures for the initiation of the individualized supervision plan upon hiring each paraprofessional.

This Rule is not met as evidenced by:

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Based on record reviews and interviews, the



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facility management failed to assure paraprofessional staff received supervision from a Qualified Professional (QP) or Associated Professional (AP) affecting 3 of 3 audited current staff (#1; #2; #3) and 2 of 2 audited former staff (FS #4 & FS #5.) The findings are:

Review on 2/7/19 of Staff #1's personnel file revealed:- an "Independent Contract Agreement" signed 11/12/18 documenting employment as a paraprofessional staff to provide direct care to clients.- no documentation of an individualized supervision plan.- no documentation the staff received supervision from a QP or AP.

Review on 2/7/19 of Staff #2's personnel file revealed:- hire date of 4/5/18 as Direct Care Staff for the facility.- also works in the Licensees' Day Program as the one-on-one staff for a client from another one of the Licensee's facilities. - no documentation the staff received regular supervision from a QP or AP based on an individualized supervision plan.

Review on 2/7/19 of Staff #3's personnel file revealed:- hire date of 11/18/17- primary work responsibility as staff in the Licensees' Day Program. However, works as Direct Care Staff in the facility on an "as needed" basis. - no documentation the staff received regular supervision from a QP or AP as noted in an individualized supervision plan.



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Review on 2/7/19 of FS #4's personnel file revealed:- no documentation of a hire date.- no documentation of an individualized supervision plan.- no documentation of supervision from a QP or AP during his employment.

Review on 2/7/19 of FS #5's personnel file revealed:- hire date of 11/18/13 as a Habilitation Technician and voluntarily terminated his employment in January 2019.- documentation of an individualized supervision plan with the last supervision from a QP or AP completed on 10/24/17. - no documentation of additional supervision after 10/24/17.

Interview on 2/8/19 with the QP confirmed:- Staff participated in staff meetings and received training on providing services to clients every payday from the facility's Program Manager. - However, she had not documented the supervision staff received according to an individualized supervision plan.- Staff personnel files did not contain documentation they had received individualized supervision from a QP or AP based on individualized supervision plans.

V 112 27G .0205 (C-D) Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND TREATMENT/HABILITATION OR SERVICE PLAN(c) The plan shall be developed based on the assessment, and in partnership with the client or

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legally responsible person or both, within 30 days of admission for clients who are expected to receive services beyond 30 days.(d) The plan shall include:(1) client outcome(s) that are anticipated to be achieved by provision of the service and a projected date of achievement;(2) strategies;(3) staff responsible;(4) a schedule for review of the plan at least annually in consultation with the client or legally responsible person or both;(5) basis for evaluation or assessment of outcome achievement; and(6) written consent or agreement by the client or responsible party, or a written statement by the provider stating why such consent could not be obtained.

This Rule is not met as evidenced by:Based on record review, interviews and observation, the facility management failed to assure 2 of 3 audited clients (#1 & #3) needs were met. The findings are:

Review on 2/1/19 of Client #1's chart revealed:- Admission date of 4/30/15- Diagnoses of Asperger's Disorder; Borderline Intellectual Functioning; Bipolar Mood Disorder; Oppositional Defiant Disorder,Unspecified; Paraphilic Disorder; Generalized Anxiety Disorder; Asthma; Hydrotylase Deficiency; Vitamin D Deficiency; Severe Peanut Allergy & History of Child Sexual Abuse, Victim and



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Perpetrator- An Independent Service Plan (ISP) dated 10/18/18 documented some of the client's needs as reported by his father/guardian: "What is working for me:" 1) needs to be kept feeling safe, self worth and belonging2) needs a structured routine, environment and daily schedule3) Father/guardian further reported "I may want to move [Client #1] to another home - there is a housemate that is causing him problems."

Review on 2/6/19 of Client #2's chart revealed:- Admission date of 10/11/17- Diagnoses of Autistic Disorder; Tourette's Syndrome; Unspecified Disruptive Impulse Control; Conduct Disorder; Intermittent Explosive Disorder; Severe Intellectual Developmental Disability; Schizophrenia; Borderline Diabetes; Gastroesophageal Reflux Disease and Seizure Disorder

Additional review on 2/1/19 of a physician's documentation dated 1/17/19 revealed Client #1:- has increased anxiety and does not feel safe in the facility- "his safety is at risk" because of "an abusive member of the home that is breaking things and scaring him." - has trouble sleeping due to the stress he feels caused by the referenced client (Client #2) who "has a lot of outburst" and "is dangerous when he has outburst" - Client #2 has been taking a bath in Client #1's bathroom every night since Client #2 broke the shower in his own bathroom. He is "concerned [Client #2] will break his shower too."

Observation on 2/7/19 at approximately 6:30 PM



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of Client #1's bathroom revealed the bathroom was located in the bedroom and could not be accessed without going into and through the client's bedroom area.

Observation on 2/7/19 at approximately 6:45 PM of the facility revealed:- Bathroom usually used by Client #2 was located next to his bedroom.- Shower head appeared to be newly installed. However, the water did not flow when faucets were turned for tub or shower. Water was only working in sink area.

During interview on 2/7/19, Client #1 said:- He was afraid of Client #2.- Client #2 has verbally threatened to kill him, however he has never been physically attacked by the client.- He made a complaint to the Licensee however, he feels he was "ignored multiple times." He does not feel anything has been done to help him feel safe at the facility.

Interview on 2/8/19 with the Qualified Professional revealed:- Client #1's concerns have been addressed.- Repairs are in process for Client #2's bathroom. The shower has been repaired, however, the faucets still need to be replaced so the water will be operational.- Client #2 has a 24 hour one-on-one who is responsible for supervising him at all times.- Discussion is in process with Client #1's Case Manager regarding options for moving him to a different setting to respond to his concerns about safety and increased independence.- Additionally, there are always two staff in the facility.



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Review of Client #3's record on 2/1/19 revealed:- Admission date of 4/13/17- Diagnoses of Intellectual Developmental Disability, Mild; Cerebral Palsy: Quadriplegia; Benign Hypertension & Dyslipidemia - An assessment documenting the client required:1) total assistance with feeding, dressing, bathing and toileting2) staff providing "exercise such as moving her legs."2) use of a motorized wheelchair due to limited movement in arms and legs3) use of adaptive equipment included: supportive belts, Hoyer lift and motorized wheelchair.

Observation on 2/7/19 at 7:00 PM of Client #3's bedroom revealed:- Client lying in her hospital bed which was in an inclined position. The client was propped up by pillows on her side.- A motorized wheelchair was also in the room.- No supportive belts or Hoyer lift were observed in the room.

Interview with staff on duty revealed:- Client #3 is seated in her wheelchair without repositioning for long periods of time because she is at the Licensee's Day Program from approximately 9:00 AM until she returns home at approximately 6:00 PM.- Staff at the Day Program do not move or "exercise" the client's legs when she is at the Day Program.- When she is in the home, staff use pillows to help move and support the client for some level of activity/movement and to help prevent skin breakdown, - Two staff were required to move Client #3 from the bed to her wheelchair. Staff complete this task by holding her on each side, supporting her



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by her back and arms and lifting her into her wheelchair.- They do not have use of supportive belts or a Hoyer lift to help them move the client.- The Client #3's Hoyer lift has been broken for several months and staff do not have use of a lift.

Review on 2/8/19 of the facility's "Care Coordination & Medical Visit Form" provided by the Medication/Medical Supervisor as proof a request for the equipment Client #3 needed revealed:- Client #3 was taken to the doctor for "Possible UTI (urinary tract infection), new electric bed order, new electric wheelchair order."- Additional information under "Needs and Recommendation Section" completed by the Medication/Medical Supervisor documented "Consumer needs new order for full electric hospital bed, also needs order for electric wheel chair, and has possible UTI. Please have provider (doctor) fill out comment section and sign this document."- The request, signed by the Medication/Medical Supervisor, was dated 2/7/19.- However, the physician's documentation only addressed Client #3's medical problem and was dated 2/5/16. No reference was made to the request for new equipment for the client.

During interview on 3/1/19, the Qualified Professional said:- The client does not have use of a lift in the facility.- She was unable to explain the inconsistencies on the form (dates of signatures) or why a request had not been made for the client's physician to order Client #3 a new Hoyer Lift.- Client #1 had a Hoyer lift at the Licensee's Day Program. However the staff from the client's



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LME/MCO had informed them they should not use the lift in the Day Program. She was unable to identify who gave this direction or when this instruction was given.

V 120 27G .0209 (E) Medication Requirements

10A NCAC 27G .0209 MEDICATION REQUIREMENTS(e) Medication Storage: (1) All medication shall be stored: (A) in a securely locked cabinet in a clean, well-lighted, ventilated room between 59 degrees and 86 degrees Fahrenheit;(B) in a refrigerator, if required, between 36 degrees and 46 degrees Fahrenheit. If the refrigerator is used for food items, medications shall be kept in a separate, locked compartment or container;(C) separately for each client;(D) separately for external and internal use;(E) in a secure manner if approved by a physician for a client to self-medicate.(2) Each facility that maintains stocks of controlled substances shall be currently registered under the North Carolina Controlled Substances Act, G.S. 90, Article 5, including any subsequent amendments.

This Rule is not met as evidenced by:

V 120

Based on record reviews, interviews and observations, the facility staff failed to assure client's external and internal medications were stored separately affecting 1 of 3 clients (#1.) The findings are:

Review on 2/1/19 of Client #1's chart revealed:



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- Admission date of 4/30/15- Diagnoses of Asperger's Disorder; Borderline Intellectual Functioning; Bipolar Mood Disorder; Oppositional Defiant Disorder,Unspecified; Paraphilic Disorder; Generalized Anxiety Disorder; Asthma; Hydrotylase Deficiency; Vitamin D Deficiency; Severe Peanut Allergy & History of Child Sexual Abuse, Victim and Perpetrator- Physician's orders included: a) internal medications to be administered: Clonazepam 0.5mg; Divalproex DR 500mg; Synthroid 50mcg; Eskalith 300mg; Seroquel 100mg and Vitamin D3 2000b) external medications: Benzoyl 5% Lotion; Clindamycin Ph 1%; Differin Gel 0.3% and Miconazole Powder 85gm.

Interview on 2/6/19 with staff on duty in the facility confirmed:- Client #1's internal medications were not stored separately from external medications.

V 131 G.S. 131E-256 (D2) HCPR - Prior Employment Verification

G.S. §131E-256 HEALTH CARE PERSONNEL REGISTRY(d2) Before hiring health care personnel into a health care facility or service, every employer at a health care facility shall access the Health Care Personnel Registry and shall note each incident of access in the appropriate business files.

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This Rule is not met as evidenced by:Based on record reviews, interviews and observations, facility management failed to complete a HCPR check for all staff prior to hire affecting 1 of 3 audited current staff (#1) and 1 of 2 audited former staff (FS #4.) The findings are:

Review on 2/7/19 of Staff #1's personnel file revealed:- an "Independent Contract Agreement" signed 11/12/18 documenting employment as a paraprofessional staff to provide direct care to clients.- no documentation a HCPR check was completed prior to employment.

Review on 2/7/19 of FS #4 personnel file revealed:- No documentation of a hire date.- The staff's signature in client records documenting he provided direct care services to clients in the facility through January 2019.

Interview on 2/8/19 with the Qualified Professional confirmed:- The HCPR check was not completed for Staff #1 who was employed as an "Independent Contract" employee.- FS #4 provided direct care to clients on an as "needed basis" through January 2019. - A HCPR check was not completed prior to his work with the clients in the facility. However, he was no longer employed with the agency.

V 133 G.S. 122C-80 Criminal History Record Check

G.S. §122C-80 CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN APPLICANTS FOR EMPLOYMENT.

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(a) Definition. - As used in this section, the term "provider" applies to an area authority/county program and any provider of mental health, developmental disability, and substance abuse services that is licensable under Article 2 of this Chapter.(b) Requirement. - An offer of employment by a provider licensed under this Chapter to an applicant to fill a position that does not require the applicant to have an occupational license is conditioned on consent to a State and national criminal history record check of the applicant. If the applicant has been a resident of this State for less than five years, then the offer of employment is conditioned on consent to a State and national criminal history record check of the applicant. The national criminal history record check shall include a check of the applicant's fingerprints. If the applicant has been a resident of this State for five years or more, then the offer is conditioned on consent to a State criminal history record check of the applicant. A provider shall not employ an applicant who refuses to consent to a criminal history record check required by this section. Except as otherwise provided in this subsection, within five business days of making the conditional offer of employment, a provider shall submit a request to the Department of Justice under G.S. 114-19.10 to conduct a criminal history record check required by this section or shall submit a request to a private entity to conduct a State criminal history record check required by this section. Notwithstanding G.S. 114-19.10, the Department of Justice shall return the results of national criminal history record checks for employment positions not covered by Public Law 105-277 to the Department of Health and Human Services, Criminal Records Check Unit. Within five



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business days of receipt of the national criminal history of the person, the Department of Health and Human Services, Criminal Records Check Unit, shall notify the provider as to whether the information received may affect the employability of the applicant. In no case shall the results of the national criminal history record check be shared with the provider. Providers shall make available upon request verification that a criminal history check has been completed on any staff covered by this section. A county that has adopted an appropriate local ordinance and has access to the Division of Criminal Information data bank may conduct on behalf of a provider a State criminal history record check required by this section without the provider having to submit a request to the Department of Justice. In such a case, the county shall commence with the State criminal history record check required by this section within five business days of the conditional offer of employment by the provider. All criminal history information received by the provider is confidential and may not be disclosed, except to the applicant as provided in subsection (c) of this section. For purposes of this subsection, the term "private entity" means a business regularly engaged in conducting criminal history record checks utilizing public records obtained from a State agency.(c) Action. - If an applicant's criminal history record check reveals one or more convictions of a relevant offense, the provider shall consider all of the following factors in determining whether to hire the applicant:(1) The level and seriousness of the crime.(2) The date of the crime.(3) The age of the person at the time of the conviction.(4) The circumstances surrounding the



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commission of the crime, if known.(5) The nexus between the criminal conduct of the person and the job duties of the position to be filled.(6) The prison, jail, probation, parole, rehabilitation, and employment records of the person since the date the crime was committed.(7) The subsequent commission by the person of a relevant offense.The fact of conviction of a relevant offense alone shall not be a bar to employment; however, the listed factors shall be considered by the provider. If the provider disqualifies an applicant after consideration of the relevant factors, then the provider may disclose information contained in the criminal history record check that is relevant to the disqualification, but may not provide a copy of the criminal history record check to the applicant.(d) Limited Immunity. - A provider and an officer or employee of a provider that, in good faith, complies with this section shall be immune from civil liability for:(1) The failure of the provider to employ an individual on the basis of information provided in the criminal history record check of the individual.(2) Failure to check an employee's history of criminal offenses if the employee's criminal history record check is requested and received in compliance with this section.(e) Relevant Offense. - As used in this section, "relevant offense" means a county, state, or federal criminal history of conviction or pending indictment of a crime, whether a misdemeanor or felony, that bears upon an individual's fitness to have responsibility for the safety and well-being of persons needing mental health, developmental disabilities, or substance abuse services. These crimes include the criminal offenses set forth in



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any of the following Articles of Chapter 14 of the General Statutes: Article 5, Counterfeiting and Issuing Monetary Substitutes; Article 5A, Endangering Executive and Legislative Officers; Article 6, Homicide; Article 7A, Rape and Other Sex Offenses; Article 8, Assaults; Article 10, Kidnapping and Abduction; Article 13, Malicious Injury or Damage by Use of Explosive or Incendiary Device or Material; Article 14, Burglary and Other Housebreakings; Article 15, Arson and Other Burnings; Article 16, Larceny; Article 17, Robbery; Article 18, Embezzlement; Article 19, False Pretenses and Cheats; Article 19A, Obtaining Property or Services by False or Fraudulent Use of Credit Device or Other Means; Article 19B, Financial Transaction Card Crime Act; Article 20, Frauds; Article 21, Forgery; Article 26, Offenses Against Public Morality and Decency; Article 26A, Adult Establishments; Article 27, Prostitution; Article 28, Perjury; Article 29, Bribery; Article 31, Misconduct in Public Office; Article 35, Offenses Against the Public Peace; Article 36A, Riots and Civil Disorders; Article 39, Protection of Minors; Article 40, Protection of the Family; Article 59, Public Intoxication; and Article 60, Computer-Related Crime. These crimes also include possession or sale of drugs in violation of the North Carolina Controlled Substances Act, Article 5 of Chapter 90 of the General Statutes, and alcohol-related offenses such as sale to underage persons in violation of G.S. 18B-302 or driving while impaired in violation of G.S. 20-138.1 through G.S. 20-138.5.(f) Penalty for Furnishing False Information. - Any applicant for employment who willfully furnishes, supplies, or otherwise gives false information on an employment application that is the basis for a criminal history record check under this section



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shall be guilty of a Class A1 misdemeanor.(g) Conditional Employment. - A provider may employ an applicant conditionally prior to obtaining the results of a criminal history record check regarding the applicant if both of the following requirements are met:(1) The provider shall not employ an applicant prior to obtaining the applicant's consent for criminal history record check as required in subsection (b) of this section or the completed fingerprint cards as required in G.S. 114-19.10.(2) The provider shall submit the request for a criminal history record check not later than five business days after the individual begins conditional employment. (2000-154, s. 4; 2001-155, s. 1; 2004-124, ss. 10.19D(c), (h); 2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:Based on record reviews, interviews and observations, facility management failed to complete a state and national criminal history record check for 1 of 3 audited current staff (#1) and 2 of 2 audited former staff (FS #4 & #5) within five days of the offer of employment. The findings are:

Review on 2/7/19 of Staff #1's personnel file revealed:- an "Independent Contract Agreement" signed 11/12/18 documenting employment as a paraprofessional staff to provide direct care to clients.- no documentation a state and criminal records check was completed within the timeframe of the offer of employment.



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Review on 2/7/19 of FC #4's personnel file revealed:- No documentation of a hire date.- Documentation in client records of services provided through January 2019.

Review on 2/7/19 of FS #5's personnel file revealed:- Hire date of 11/18/13.- Documentation a criminal record check was completed on 10/21/13 - not within the required five-day timeframe.- Voluntary terminated his employment in January 2019.

Interview on 2/8/19 with the Qualified Professional confirmed:- The HCPR check was not completed for Staff #1 who was employed as an "Independent Contract" employee.- FS #4 provided direct care to clients on an as "needed basis" through January 2019. - His criminal record check was not completed prior to his work with the clients in the facility. However, he was no longer employed with the agency.- The criminal record check was completed prior to her hire and was not completed for FS #5 within the required time frame.

V 736 27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS(c) Each facility and its grounds shall be maintained in a safe, clean, attractive and orderly manner and shall be kept free from offensive odor.

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This Rule is not met as evidenced by:Based on observations and interviews, the facility management failed to assure the facility was maintained in a safe, clean and orderly manner. The following are findings:

Observation on 2/7/19 at approximately 6:45 PM of the facility revealed the following issues:- Kitchen area:The handles on the side by side refrigerator were tied together with a rope/cord looped around the handles on both sides. - Bathroom next to Client #2 and #3's bedrooms: the water did not flow when faucets were turned for tub or shower.

During interview on 2/7/19, staff on duty said:- The refrigerator and freezer door had to be tied together so they could remain closed.- The water had not been working in the bathroom next to Client #3's bedroom for several months. It stopped working after the showerhead was repaired/replaced. - Management had been made aware the water in the bathroom was not working.

This deficiency constitutes a re-cited deficiency and must be corrected within 30 days.



I Innovations, Inc. - 2071 Heritage Way, 2071 Heritage Way, Cameron, NC 28326 - POC Response

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1. V 108 27G .0202 (F-I) Personnel Requirements 10A NCAC 27G .0202

PERSONNEL REQUIREMENTS

Indicate what measures will be put in place to correct the deficient area of practice (i.e.

changes in policy and procedure, staff training, changes in staffing patterns, etc.):

I Innovations, Inc. will abide by rule: V 108 27G .0202 (F-I) Personnel Requirements 10A

NCAC 27G .0202 PERSONNEL REQUIREMENTS

Owner, Program Manager, and Quality Management met on 3/17/19 to review and discusses the

Follow-Up and Complaint Survey completed March 4, 2019: I Innovations, Inc. - 2071 Heritage

Way, 2071 Heritage Way, Cameron, NC 28326. (Intake #NC00148024).

To make sure that I Innovations, Inc. complies with the personnel rule stated above, Owner,

Program Manager, and Quality Management implemented a Human Resource (HR) Flow Chart,

Personnel Audit Tool, and HR Spreadsheet that will be used audit tools to ensure compliance

with the deficient area of practice.

➢ To correct the deficient area of practice, the Program Manager developed an HR Flow

Chart that will be used as a check-off list during the hiring process to ensure compliance

with personnel charts; to include required training pertaining their job title.

• Please see attached HR Flow Chart

➢ To correct the deficient area of practice, the Program Manager and Quality Management

developed a Personnel Audit Tool to utilize for auditing Personnel Charts. The tool will

be used to help identify personnel requirements to include staff training.

• Please see attached I Innovations, Personnel Audit Tool.


conducted an in-house HR Audit on 3/20/19 to ensure compliance with staff charts; to

include the items listed in the personnel requirements: V 108 27G .0202 (F-I) Personnel

Requirements 10A NCAC 27G .0202 PERSONNEL REQUIREMENTS; to include staff

training.

• To correct the deficient area of practice the Agency will provide required trainings to

staff members that need training, additional training, and or have expired trainings to

ensure compliance.


developed an HR Tracking Spreadsheet to use for tracking Personnel Requirements. The

HR Spreadsheet will be utilized on an on-going basis to ensure compliance with

Personnel Requirements, include staff training.

• Please see HR Spreadsheet


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Indicate what measures will be put in place to prevent the problem from occurring again:



Personnel Audit Tool, and HR Spreadsheet that will be used as an audit tool to ensure

compliance with the deficient area of practice.

➢ To prevent the deficient area of practice, the Program Manager MUST utilize the HR

Flow Chart that will be used as a check-off list during the hiring process to ensure

compliance with personnel charts, include staff training.


➢ To prevent the deficient area of practice, the Program Manager and Quality Management

MUST use the Personnel Audit Tool to utilize for auditing Personnel Charts. The tool

will be used to help prevent the problem from occurring again.



will conduct on-going monthly in-house Personnel Chart audits to ensure compliance

with the personnel requirements: 10A NCAC 27G .0202 PERSONNEL

REQUIREMENTS; V 108 27G .0202 (F-I) Personnel Requirements; to include required

training.

• The Agency will provide required trainings to staff members that need training,

additional training, and or have expired trainings to ensure compliance.


MUST use the HR Tracking Spreadsheet to help track Personnel Requirements. The HR

Spreadsheet will be utilized on an on-going basis to ensure compliance with the

Personnel Requirement, to include training. The HR Spreadsheet will also be reviewed

during the on-going monthly in-house Personnel Chart Audits.


Indicate who will monitor the situation to ensure it will not occur again:

Owner, Program Manager, and Quality Management

Indicate how often the monitoring will take place:

The HR flow Chart will be used each time a direct care staff is hired to ensure compliance with

job requirements to include required training(s). The HR Spreadsheet will be monitored on an

on-going basis to ensure compliance with direct care staff requirements to include required

training.

In-house Personnel Chart Audits will be conducted monthly to ensure compliance with direct

care staff charts; Program Manager and Qualified Professional will report and discuss results

during the Quarterly Management Meeting.


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2. V 110 27G .0204 Training/Supervision Paraprofessionals, 10A NCAC 27G .0204

COMPETENCIES AND SUPERVISION OF PARAPROFESSIONALS



I Innovations, Inc. will abide by rule: V 110 27G .0204 Training/Supervision Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND SUPERVISION OF PARAPROFESSIONALS




This said, the team discussed the importance of developing an annual supervision plan for each

direct care staff and conducting monthly individual supervisions on an on-going basis by a

Qualified Professional to ensure staff competency.


developed a Personnel Audit Tool to utilize for auditing Personnel Charts. The tool will

be used to help identify personnel requirements to include staff Supervision and

Documentation of Supervision Plan.




include the items listed in the personnel requirements: V 108 27G .0202 (F-I) Personnel

Requirements 10A NCAC 27G .0202 PERSONNEL REQUIREMENTS; pertaining to

include staff Supervision and Documentation of Supervision Plan from a Qualified

Professional.

• To correct the deficient area of practice the agency will provide an Annual Supervision

Plan and monthly supervision to staff members that need Supervision and Documentation

of Supervision Plan from a Qualified Professional.


developed an HR Tracking Spreadsheet to use for tracking Personnel Requirements. The

HR Spreadsheet will be utilized on an on-going basis to ensure compliance with

Personnel Requirements, to include to include staff Supervision and Documentation of

Supervision Plan.



reviewed/revised the current Annual Supervision Plan form and Monthly Supervision

form to make sure the form meets the requirements of the: 10A NCAC 27G .0202


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PERSONNEL REQUIREMENTS; V 110 27G .0204 Training/Supervision

Paraprofessionals; to include staff Supervision and Documentation of Supervision Plan

signed by a Qualified Professional.

• Please see attached I Innovations, Inc.’s Annual Supervision Plan form and Monthly

Supervision

➢ To correct the deficient area of practice, the agency will use the revised (3/20/19) Annual

Supervision Plan form for new hires and -on-going during the time direct care staff’s

employment.

➢ To correct the deficient area of practice, the agency will use the revised (3/20/19)

Monthly Supervision for the current month of March and on-going to ensure compliance

with Supervision.

• Please see attached the agency’s Annual Supervision and Monthly Supervision

Form

Indicate what measures will be put in place to prevent the deficient area of practice (i.e.



Program Manager, and Quality Management MUST have a Qualified Professional to conduct

Annual Supervision as well as monthly individual staff supervision.

➢ To prevent the deficient area of practice, the Program Manager MUST utilize the

Personnel Chart Audit tool that is used as a check-off list during the auditing process to

ensure compliance with personnel charts, to include Supervision and Documentation of

Supervision Plan.

• Please see attached Personnel Chart Audit tool .


will use the (re-vised 3/20/19) Annual Supervision Plan form and Monthly

Supervision forms to ensure compliance with the: 10A NCAC 27G .0202 PERSONNEL

REQUIREMENTS; V 110 27G .0204 Training/Supervision Paraprofessionals to include

Supervision and Documentation of Supervision Plan signed by a Qualified Professional.

• Please see attached I Innovations, Inc.’s Annual Supervision Plan form and Monthly

Supervision


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Owner, Program Manager, Qualified Professional, and Quality Management


The HR Spreadsheet will be monitored on an on-going basis to ensure compliance with direct

care staff requirements to include required Supervision and Documentation of Supervision Plan

signed by a Qualified Professional.





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3. V 112 27G .0205 (C-D) Assessment/Treatment/Habilitation Plan 10A NCAC 27G

.0205 ASSESSMENT AND TREATMENT/HABILITATION OR SERVICE PLAN



I Innovations, Inc. will abide by rule: V 112 27G .0205 (C-D)Assessment/Treatment/Habilitation

Plan 10A NCAC 27G .0205 ASSESSMENT AND TREATMENT/HABILITATION OR

SERVICE PLAN



Way, 2071 Heritage Way, Cameron, NC 28326.(Intake #NC00148024).


Program Manager, and Quality Management will conduct weekly clinical team meetings to

discuss/review consumer progress and or updates; to include reviewing the ISP Plan and or PCP

to ensure compliance with the consumer’s plan of care.

➢ To correct the deficient area of practice, the Program Manager and Qualified Professional

will continue to attend ISP and or PCP meetings and Care-Coordination meetings with

the Care-Coordinators to discuss/review consumer progress, concerns, and or updates; to

include reviewing an individual’s assessment/treatment/habilitation plan. (Minutes will

be documented in a care-coordination note by QP and or Program Manager).

➢ To correct the deficient area of practice, I Innovations, Inc. will provide on-going

required training to staff members to gain the knowledge they need to perform their job

duties with quality care.

➢ To correct the deficient area of practice, the Program Manager and Qualified

Professionals will continue to provide monthly individual supervision to staff members to

ensure compliance with staff competency.

➢ To correct the deficient area of practice, the owner, Program Manager, and Qualified

Professional met with Client#1, Client#2, and Client#3’s Care Coordinators to discuss the

deficiencies notated. This said a plan of action is in place at this time for each of the

identified clients and will be documented in each client’s chart accordingly.

• Owner, Program Manager, and Quality Management also discussed the importance for

documenting: if to occur Level I, (II, III, and IV incidents to IRIS); to include reporting

any allegations that a consumer may have towards a staff member(s) to the Health Care

Registry to review when and if necessary.


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➢ To correct the deficient area of practice, the bathroom tub faucets and shower head

problems have been repaired and water is operating in the identified bathrooms.




Program Manager, and Quality Management will conduct weekly clinical team meetings to

discuss/review consumer progress and or updates; to include reviewing the ISP Plan and or PCP

to ensure compliance with the consumer’s plan of care.

➢ To prevent the deficient area of practice, the Program Manager and Qualified

Professional will continue to attend ISP and or PCP meetings and Care-Coordination

meetings with the Care-Coordinators to discuss/review consumer progress, concerns, and

or updates; to include reviewing an individual’s assessment/treatment/habilitation plan.

This process will prevent problems such as mentioned, and it will provide an opportunity

for the clinical team to discuss problems, concerns, changes, risk management and or any

client updates. (Minutes will be documented in a care-coordination note by QP and or

team lead).

➢ To prevent the deficient area of practice, I Innovations, Inc. will provide on-going

required training to staff members to gain the knowledge they need to perform their job

duties with quality care.

➢ To prevent the deficient area of practice, the Program Manager and Qualified

Professionals will continue to provide monthly individual supervision to staff members to

ensure compliance with staff competency.

➢ To prevent the deficient area of practice, the Program Manager and or Qualified

Professional will conduct quarterly announced/unannounced comprehensive facility

inspections to ensure compliance with a facility’s physical structure and follow up with

an in-house plan of corrections to correct the issue(s) at hand.


Owner, Program Manager, Qualified Professional, and Quality Management


Program Management/Quality Management will conduct weekly clinical team meetings to

discuss client progress/updates, to include attending on-going Care-Coordination Meetings with

Care Coordinators and provide Monthly Supervision to all direct care staff to ensure staff

competency.


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Program Management will conduct quarterly announced/unannounced comprehensive facility

inspections to ensure compliance with facility physical structure.

Annual and Monthly individual supervision will be conducted to ensure compliance with staff

competency.


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4. V 120 27G .0209 (E) Medication Requirements 10A NCAC 27G .0209 MEDICATION

REQUIREMENTS



I Innovations, Inc. will abide by rule: V 120 27G .0209 (E) Medication Requirements

10A NCAC 27G .0209 MEDICATION REQUIREMENTS.




To make sure that I Innovations, Inc. complies with the personnel rule stated above, the agency

has made a change of how medication is being checked for compliance on a daily basis; to

include proper medication storage.

➢ To correct the deficient area, the Program Manager assigned one designated Medication

Management personnel (CNA certified) staff member with a back-up staff that checks

medication daily for all licensed facilities; to include Heritage Way. The designated

person is responsible to audit the MAR daily to include how medication is being stored

and placed accordingly to the prescription order. The Program Manager will also assist

the Medication Management personnel with the daily medication auditing process.

➢ To correct the deficient area, the agency purchased separate medication containers for

each of the consumers at Heritage way to avoid medication storage errors; to include

internal/external medication errors.

➢ To correct the deficient area, the agency will provide on-going Medication

Administration training, MAR documentation training, and Medication Management

training to all direct care staff members. Trainings will be provided though the agency,

independent contractors, and or the MCO.

➢ To correct the deficient area, the agency will provide on-going medication error

documentation training to ensure compliance with documenting medication errors.



To make sure that I Innovations, Inc. complies with the personnel rule stated above, the agency

has made a change of how medication is being checked for compliance on a daily basis; to

include proper medication storage.


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➢ To prevent the deficient area, the agency MUST follow though with the current protocol

that has been implemented to ensure compliance with the medication deficiencies

notated.

➢ To prevent the deficient area, staff MUST use the medication containers to separate

medication for each of the consumers at Heritage Way to avoid medication storage

errors; to include internal/external medication errors.

➢ To prevent the deficient area, the Program Manager is responsible to monitor the

medication management process and assist the Medication Management personnel

conduct in-house medication reviews on an on-going basis to ensure compliance.

➢ To prevent the deficient area, the agency will provide on-going Medication

Administration training, MAR documentation training, and Medication Management

training to all direct care staff members. Trainings will be provided through the agency,

independent contractors, and or the MCO.

➢ To prevent the deficient area, the agency will provide on-going medication error

documentation training to ensure compliance with documenting medication errors.


Owner, Program Manager, Qualified Professional, Medication Management personnel, and

Quality Management.


Daily medication audits, to include on-going monthly in-house medication reviews at the day

center and residential homes to ensure compliance with medication administration; to include

proper medication storage.


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5. V 131 G.S. 131E-256 (D2) HCPR - Prior Employment Verification G.S. §131E-256

HEALTH CARE PERSONNEL REGISTRY



I Innovations, Inc. will abide by rule: V 131 G.S. 131E-256 (D2) HCPR - Prior Employment

Verification G.S. §131E-256 HEALTH CARE PERSONNEL REGISTRY






I Innovations, Inc. will abide by rule: 10A NCAC 27G .0202 PERSONNEL REQUIREMENTS;

V 131; G.S. 131E-256 (D2) HCPR - Prior Employment Verification; G.S. §131E-256 HEALTH

CARE PERSONNEL REGISTRY.








➢ To correct the deficient area of practice, the Program Manager created a HR Flow Chart

that will be used as a check-off list during the hiring process to ensure compliance with

personnel charts; to include the Health Care Registry requirements.



developed a Personnel Audit Tool to utilize for auditing Personnel Charts.

• Please see attached I Innovations, Personnel Audit Tool; to include the requirements

of to include the Health Care Registry requirements.


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implemented a HR Tracking Spreadsheet to use for tracking Personnel Requirements.

The HR Spreadsheet will be utilized on an on-going basis to ensure compliance with

Personnel Requirements; to include V 131 G.S. 131E-256 (D2) HCPR - Prior

Employment Verification G.S. §131E-256 HEALTH CARE PERSONNEL REGISTRY




include the items listed in the personnel requirements: V 131 G.S. 131E-256 (D2) HCPR

- Prior Employment Verification G.S. §131E-256 HEALTH CARE PERSONNEL

REGISTRY.

• To correct the deficient area of practice, the Agency will conduct HCPR Checks for all

direct care staff member’s HCPR that are missing from the direct care staff’s chart and

for all direct care staff workers who are due for an update HCPR check.



➢ To prevent the deficient area of practice, prior to hiring anyone with the agency, I

Innovations, Inc. MUST conduct a HCPR check on individuals who apply for

employment.



compliance with personnel charts; to include the Health Care Registry requirements.



MUST use the Personnel Audit Tool to utilize for auditing Personnel Charts.

• Please see attached I Innovations, Personnel Audit Tool; to include the requirements

of to include the Health Care Registry requirements.


MUST use the HR Tracking Spreadsheet for tracking Personnel Requirements. The HR

Spreadsheet will be utilized on an on-going basis to ensure compliance with Personnel

Requirements; to include V 131 G.S. 131E-256 (D2) HCPR - Prior Employment

Verification G.S. §131E-256 HEALTH CARE PERSONNEL REGISTRY



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MUST conduct monthly Personnel Chart audits to ensure compliance with direct care

staff charts.





job requirements to include required training(s). The HR Spreadsheet will be monitored on an

on-going basis to ensure compliance with direct care staff requirements to include required Prior

Employment Verification G.S. §131E-256 HEALTH CARE PERSONNEL REGISTRY.





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6. V 133 G.S. 122C-80 Criminal History Record Check G.S. §122C-80 CRIMINAL

HISTORY RECORD CHECK REQUIRED FOR CERTAIN APPLICANTS FOR

EMPLOYMENT.



I Innovations, Inc. will abide by rule: V 133 G.S. 122C-80 Criminal History Record Check

G.S. §122C-80 CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN

APPLICANTS FOR EMPLOYMENT.








➢ To correct the deficient area of practice, the Program Manager created a HR Flow Chart

that will be used as a check-off list during the hiring process to ensure compliance with

personnel charts; to include the Criminal History Record Check requirements.



developed a Personnel Audit Tool to utilize for auditing Personnel Charts.

• Please see attached I Innovations, Personnel Audit Tool; to include the requirements of

to include the Criminal History Record Check requirements.


implemented a HR Tracking Spreadsheet to use for tracking Personnel Requirements.

The HR Spreadsheet will be utilized on an on-going basis to ensure compliance with

Personnel Requirements; to include V 133 G.S. 122C-80 Criminal History Record Check

G.S. §122C-80 CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN

APPLICANTS FOR EMPLOYMENT




include the items listed in the personnel requirements: V 133 G.S. 122C-80 Criminal

History Record Check G.S. §122C-80 CRIMINAL HISTORY RECORD CHECK

REQUIRED FOR CERTAIN APPLICANTS FOR EMPLOYMENT.


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• To correct the deficient area of practice, the Agency will conduct a Criminal Background

Check (state and national) for the direct care staff members that are missing a criminal

background check from their personnel chart and for all direct care staff workers that are

due for an update.



➢ To prevent the deficient area of practice, prior to hiring anyone with the agency, I

Innovations, Inc. MUST conduct a Criminal History Record Check on individuals who

apply for employment.



compliance with personnel charts; to include the Criminal History Record Check

requirements.



MUST use the Personnel Audit Tool to utilize for auditing Personnel Charts.

• Please see attached I Innovations, Personnel Audit Tool; to include the requirements of

the Criminal History Record Check requirements.


MUST use the HR Tracking Spreadsheet to track Personnel Requirements. The HR

Spreadsheet will be utilized on an on-going basis to ensure compliance with Personnel

Requirements; to include V 133 G.S. 122C-80 Criminal History Record Check G.S.

§122C-80 CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN




Owner, Program Manager and Quality Management



job requirements to include required Criminal Back Ground Checks. The HR Spreadsheet will be

monitored on an on-going basis to ensure compliance with direct care staff requirements to

include required Prior Employment Verification: V 133 G.S. 122C-80 Criminal History Record


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Check G.S. §122C-80 CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN






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7. V 736 27G .0303(c) Facility and Grounds Maintenance, 10A NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS



I Innovations, Inc. will abide by rule: V 736 27G .0303(c) Facility and Grounds Maintenance,

10A NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS.




To make sure that I Innovations, Inc. complies with the V 736 27G .0303(c) Facility and

Grounds Maintenance, 10A NCAC 27G .0303 LOCATION AND EXTERIOR

REQUIREMENTS rule stated above, Owner, Program Manager, and Quality Management

created COMPREHENSIVE HEALTH & SAFETY INSPECTION – SELF INSPECTION tool

to use when conducting facility health safety inspections and or facility and grounds maintenance

inspections. The tool will be used as a check-off list to conduct facility health safety inspections

and or facility and grounds maintenance inspections.

➢ To correct the deficient area, (the kitchen area): The agency replaced the old refrigerator with a new one.

➢ To correct the deficient area, (bathroom next to Client #2 and #3 bedrooms): The water problem in this bathroom has been fixed and there is currently running water for the tub

and shower.

➢ To correct the deficient area, (bathroom next to Client #3 bedrooms): The water problem

in this bathroom has been fixed and there is currently running water for the tub and

shower.

➢ To correct this deficient area, Program Manager and or Qualified Professional will conduct quarterly (announced and or un-announced) facility and grounds maintenance

inspections for all I Innovations, Inc. facilities to include Heritage way -to ensure

compliance with rule: V 736 27G .0303(c) Facility and Grounds Maintenance, 10A

NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS

• Please see attached: COMPREHENSIVE HEALTH & SAFETY INSPECTION – SELF INSPECTION tool.


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To make sure that I Innovations, Inc. complies with the V 736 27G .0303(c) Facility and

Grounds Maintenance, 10A NCAC 27G .0303 LOCATION AND EXTERIOR

REQUIREMENTS rule stated above, Owner, Program Manager, and Quality Management

created COMPREHENSIVE HEALTH & SAFETY INSPECTION – SELF INSPECTION tool

to use when conducting facility health safety inspections and or facility and grounds maintenance

inspections. The tool will be used as a check-off list to conduct facility health safety inspections

and or facility and grounds maintenance inspections.

➢ To prevent this deficient area, Program Manager and or Qualified Professional will conduct quarterly (announced and or un-announced) facility and grounds maintenance

inspections for all I Innovations, Inc. facilities to include Heritage Way - to ensure

compliance with rule: V 736 27G .0303(c) Facility and Grounds Maintenance, 10A

NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS

• Please see attached: COMPREHENSIVE HEALTH & SAFETY INSPECTION – SELF INSPECTION tool.

➢ To prevent this deficient area, the inspector is required to document the findings during the inspection and correct the issue(s) accordingly and in a timely manner.




Program Manager and or Qualified Professional will conduct quarterly (announced and or un-

announced) facility and grounds maintenance inspections for all I Innovations, Inc. facilities; to

include Heritage Way.

I Innovations, Inc.

1952 S. Horner Blvd Sanford, NC 27330

Bus: 919-776-8972 Fax: 919-708-5514

Cell: 910.624.9396 Email: [email protected]

I Innovations, Inc. 02/15/2017, Revised: 3/20/19 TR 1

Clinical Supervisory Conference

Annual Supervision Plan

Employee: _______________________________

Supervision Date: ______________ Review By Date: _________ (Not to Exceed One Year)

Issues discussed

• Meet Objectives Per Job Description: 1. Adhere to all agency pol

nc dhsr mhlcs: plan of correction...2019/03/27 · observation, the facility management failed to...

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