SOARING HOUSE

PLAN OF CORRECTION – 41NM11PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE.1. A description of how the licensee will correct each identified deficiency. The facility will continue to ensure activities (both within the facility and out in the community) occur regularly and that residents are engaged, to the extent they desire, and their condition allows them to engage with activities and in the community. The facility will ensure that these activities along with resident participation in these activities is appropriately documented. The activity calendar will be specific, detailed, and updated with the activities being offered. If an outing needs to be updated, or the participants choose to change the activity, the calendar will be updated promptly to reflect the change. The activity calendars will be posted and reflect the current outside activity offerings and internal activity offerings. Staff will record participation in these activities in the participants’ daily case notes and individualized service / support plans. The facility has hired a Lead staff member and they will assist in updating the activity calendar and make certain all activities are listed and occurring as scheduled within and outside of the facility. This is a primary duty of the Lead staff member to keep this calendar updated and activities tracked. The Lead staff member will also continue to conduct a monthly participant meeting with the participants along with the Assistant Director of the facility. As a part of this meeting, participants of the home choose the activities they wish to do. They particularly enjoy shopping and wish to go out to do so twice a month. Additional community outings occur on opposite weeks of shopping to include other activities of the participants’ choice such as movies, bowling, sporting events, going out to eat, etc. Community outings, including shopping trips, and trips to the movies, will occur on a weekly basis, weather and staffing permitting. The participants will also continue to be offered structured activities daily in the facility. The morning activities will reflect each of participants’ specific individualized service/support plans and person-centered goals. Activities that are often a part of individual goals include things such as working on household skills, cooking, baking, budgeting, volunteering, job skills, personal hygiene skills, working on rehabilitation skills involving their brain injury, etc. Staff will then document on these goals for each individual. The afternoon activities will be of participants’ choosing and may include book club, trivia, puzzles, board games, music, exercise, yoga therapy, music, and other activities that support individuals with brain injuries and are reflective of the participants wants and desires. Staff will document on these activities in the participants case notes. The facility also has medical navigators that support resident engagement with the community by taking residents to appointments and errands either individually or with other residents. If residents desire, these navigators will continue to take them on community outings of their choice (e.g. one on one time with the navigator over coffee or lunch, for shopping, to the beautician or barber shop, etc.) in conjunction with their appointments. Staff will document these community activities in the participants case notes. 2. A description of how the licenseewill monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The lead of the facility will complete a weekly report for the next month (the first month) outlining a check of the activity calendar being updated and posted, a check to ensure that activities are being offered daily within the facility, and a check to ensure weekly outings outside of the home are being completed per the participants’ choosing. A quality management program will also be added specific to activities and the weekly report from the lead of the facility will be reviewed as part of the monthly quality management program. Following the first month, the Lead will do a bi-weekly report of the checks detailed above and file the biweekly reports for the following two months and these reports will also be reviewed as part of the monthly quality management program review and updates. 3. A completion date that shall be no longer than thirty (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in the plan of correction by 1/9/25.