Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(d) | Individuals were not able to evacuate the entire building within 2 1/2 minutes during the following fire drills:
11/10/2021 - 4 minute and 9 second evacuation time. 10/25/2021 - 3 minute and 20 second evacuation time. 9/21/2021 - 2 minute and 45 second evacuation time. 8/22/2021 - 3 minute and 42 second evacuation time. 4/20/2021 - 3 minute and 12 second evacuation time. 3/31/2021 - 5 minute evacuation time. 2/19/2021 - 2 minute and 47 second evacuation time. 1/22/2021 - 2 minute and 52 second evacuation time. 12/21/2020 - 4 minute and 47 second evacuation time. 11/17/2020 - 4 minutes and 14 seconds. The home does not have an extended evacuation time, designated in writing by a fire safety expert, within the past 12 months. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | 1. Fire Chief sent letter on 12/10/2021 clarifying evacuation time, but additional required regulatory content was missing.
2. Program Director sent new request on 12/28/2021 with sample template and copy of required regulatory content clearly identified. Support document #1.
3. Proof of the Fire Chief's certification was obtained on 12/29/2021. Support document #2.
4. Program Director will contact Fire Chief on a daily basis and ensure new letter with all regulatory content is obtained by 1/10/2022. |
01/10/2022
| Implemented |
6400.51(b)(1) | Direct Service Worker #2, hire date of 11/01/2021, did not complete the following training during orientation or within 30-days from date of hire: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | DSW #2 completed trainings on person-centered practices, community integration, consumer choice, and developing/maintaining relationships by 11/2/2021 as evidenced by Person Centered Planning for Individuals with Developmental Disabilities, People with Disabilities: Building Relationships and Community Membership, and Everyday Lives trainings in Relias. Support document #3. |
11/02/2021
| Implemented |
6400.52(c)(1) | Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Executive Director completed training on person-centered practices, community integration, consumer choice, and developing/maintaining relationships on 12/22/2021 as evidenced by Everyday Lives training in Relias. Support document #5. |
12/22/2021
| Implemented |
6400.52(c)(3) | Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Executive Director completed training on consumer rights on 12/22/2021 as evidenced by Rights of Individuals with IDD training in Relias. Support document #5. |
12/22/2021
| Implemented |
6400.52(c)(4) | Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Executive Director completed training on incident management on 12/22/2021 as evidenced by DCI I.M. Policy training in Relias. Support document #5. |
12/22/2021
| Implemented |