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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | Individual # 2's bedroom is attached to a finished attic space which does not have a window. The bedroom has an air conditioner in the bedroom window, however, the finished attic room does not have a window. The room had an oscillating table fan, however the temperature in the attic room was much warmer than the bedroom, which was cooled by the window air conditioner. Health and safety concerns are for Individual # 2 spending time in the finished attic room with the potential for the temperature rising to an unsafe level without alternative mechanical ventilation or a window. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| We have not had to approach this issue before so have temporarily installed a fan to help pull the cool air from the bedroom into the attic room until a permanent solution can be found, as well as relocating the fan in the bedroom to aim the cool air into the attic. The size of the window precludes a window fan, as it is too narrow for any fans on the market. The window in the attic does not go to the outside, but rather to an open space over the office, precluding installation of a window A/C unit. There are no openings to vent to the outside. We had H&H service give us an estimate for a vented system and his estimate is $9,500. We thought we could install a larger unit in the bedroom but it is already an 8,000btu unit and not sure a 10,000 btu unit would be sufficient. Looking at the options, we feel that a portable A/C is how we will need to go to ensure the room is cool. We will have that purchased and running no later than 9/15/20. We also installed a thermometer in the room to assist in monitoring the temperature. I am confident the portable unit will be installed and running before the end of this month, but giving a little leeway in case of any issues. Of course, I will let you know when installed. Our Property Manager is responsible for purchasing and installing the unit. [See Attachment #4.] |
09/15/2020
| Implemented |
| 6400.112(e) | According to the fire drill logs there was a sleep drill completed April 2020, so the previous sleep drill would have to be completed in the month of October 2019. Fire drill records detail that a sleep drill was attempted on dates 10/07/19, 10/11/19, 10/14/19, 10/17/19, 10/24/19,10/26/19, 10/30/2019, 10/31/19; however, all of them were unsuccessful. The provider must continue sleep drill attempts until a successful sleep drill is accomplished in order to be in compliance. There is documentation that there was a successful drill on 10/28/2019, however it wasn't a sleep drill. | A fire drill shall be held during sleeping hours at least every 6 months. | One individual is the cause of the unsuccessful sleep drills. She came to CPARC on 7/18/19 as an Emergency Respite (evolved into a permanent placement), and received Fire Safety Training the same day. She did participate in several awake drills that were successful, however, failed to evacuate on numerous occasions during sleep drills. This is not an excuse, but our regular pre-admittance plans to a residential placement include overnights where a sleep drill is performed, to ensure the individual can/will evacuate. As she was an Emergency Respite placement, we did not have that opportunity. Following the dates listed
A social story was developed regarding drills, and staff worked with the individual on this. The Program Supervisor monitored the awake overnight staff to see if there were any suggestions to have a successful drill. Sleep drills were held by staff, other than the overnight staff, to see if that was a concern. It was not and the attempts were not successful. A visit to the local fire company occurred where the firemen explained the importance of evacuating. When individual successfully evacuated during awake drills, stickers were given her to encourage her. The local fire department came to the home and did fire safety training for all residents and staff.
Communication Support was arranged and per the specialists recommendation an iPAD and `Prolotogo was to be downloaded as well as `Pictello so that social stories could be developed for fire drills that was hoped would be more effective. YouTube videos were watched on fire safety. The Supports Coordinator was contacted in March to make a referral for a technology assessment to be complete to assess for potentially a bed shaker or other technology. After numerous follow up calls to the SC, the last correspondence on 7/8/20 the SC said she was laying phone tag with UCP but did talk and the UCP rep would talk it over with their supervisor and get back to the SC. We have heard nothing to date.
The individual did not like her bedroom, did not feel comfortable in it, and relocated to a different bedroom in the home on 4/7/20, where she has successfully completed a sleep drill on 4/21/20, and again on 8/13/20. Staff will be holding a sleep fire drill each month, to get KD in the habit of responding to the alarm.
After the numerous failed attempts listed in the cite, staff attempted many more (see Attachment #3) with just KD as the other individuals in the home were frustrated/angry and didnt want to get up. Our concern was that if it were a real alarm they would not respond. For now, it appears we are on a positive track with KD participating in the sleep drill.
We shall continue to monitor, run sleep drills monthly and pursue technology assistance. As the Program Supervisor position is vacant at the moment, the Program Specialist is responsible for ensuring these drills occur. Please see Attachment #3 for documentation. The plan is ongoing so there is no 'Correction' date, but the plan was decided upon on 72/0/20 and will continue per the above. |
07/20/2020
| Implemented |
| 6400.181(f) | Individual # 1's Annual Assessment was sent to team members on 04/01/20. An Individual Support Plan (ISP) meeting was held on 04/03/20. The program specialist did not provide the assessment to the individual plan team members at least 30 calendar days prior to the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | On 7/30/20, all Program Specialists and Associate Directors were re-trained on the timing of when an individuals Assessment is due to the team [Attachment #2a, Training Signature Sheet/Handout]. The tools at their disposal are Attachment #2b, Calendar of Due Dates and Attachment #2c, Assessment Check List]. The Associate Director reviews the Assessment Check List once the process is completed and if late will work with the Program Specialist to ensure timeliness moving forward. |
07/30/2020
| Implemented |
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