| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.31(b) | A statement signed and dated by Individual #1 acknowledging receipt of the information on individual rights to be completed annually was not completed. | A statement signed and dated by the individual, or the individual's parent, guardian or advocate if appropriate, acknowledging receipt of the information on individual rights upon admission and annually thereafter, shall be kept. | Individual rights were reviewed with the consumer on 11/25/14. Statement was signed and copy will be emailed. This item has also been added to the Quarterly Inspection form, which will be submitted via email. |
12/05/2014
| Implemented |
| 6500.43(e) | Staff Person #2 does not have the educational qualifications and work experience required for the position of the family living specialist. | A family living specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with mental retardation. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with mental retardation. (3)An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with mental retardation. (4) A high school diploma or general education development certificate and 6 years work experience working directly with persons with mental retardation. | The Family Living Specialist has over 60 credit hours at an accredited university and over 4 years work experience with persons with mental retardation. A "file" of information was previously submitted related to this position in response to the plan of correction for the adult training faciliity for this provider that occurred during the same inspection visit.[On 3/2/15, Program Director submitted to DHS the qualifications for two new program specialists who will be sharing the program specialist duties. (AS 3/4/15)] |
12/05/2014
| Implemented |
| 6500.45(b) | Staff Person #1, the primary caregiver, had training in first aid on 11/15/12 that was valid for 2 years. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | The primary caregiver was trained in first aid and Heimlich techniques on 12/3/14. Documentation will be submitted via email. This item will be monitored by the Program Supervisor via the Quarterly Inspection process, and has also been added to an internal provider tracking system for training dates. |
12/05/2014
| Implemented |
| 6500.45(c) | Staff Person #1, the primary caregiver, had training in cardiopulmonary resuscitation on 11/15/12 that was valid for 2 years. | The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter | The primary caregiver was trained in CPR on 12/3/14. Documentation will be submitted via email. This item will be monitored using the Quarterly Inspection process, and this item has also been added to an internal tracking system for training dates. |
12/05/2014
| Implemented |
| 6500.68(b) | The hot water temperature at the bathtub in the bathroom on the main living level measured 136.7 degrees Fahrenheit at 10:00 AM. | Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F. | The lifesharing provider turned down the thermostat on the hot water tank on the day of inspection. The provider has since checked the water temperature on three different days and the temperature has read between 117 and 120 degrees. A statement from the provider will be submitted via email. This issue will also be monitored quarterly using the Supervisor's quarterly inspection process. |
12/05/2014
| Implemented |
| 6500.79(c) | The bedroom in the basement of the home does not have a window. | A bedroom shall have at least one exterior window that permits a view of the outside. | The construction on the basement bedroom has been changed to include an exterior windown that permits a view of the outside. A picture of the window will be submitted via email. |
12/05/2014
| Implemented |
| 6500.83(b) | The above ground swimming pool has 3 steps leading to a deck which is not gated and abuts the pool. The individuals living in the home are not able to swim. | An above ground swimming pool shall be made inaccessible to individuals when the pool is not in use. | The pool has a cover, and the cover was on the pool and intact at the time of inspection. The pool now also has a gated entry. A picture of the pool and surrounding area will be submitted via email. This item will be monitored by the program Supervisor via the quarterly inspection checklist. |
12/05/2014
| Implemented |
| 6500.151(e)(14) | The assessment for Individual #1, dated 1/31/14, did not include the individual's knowledge of water safety and ability to swim. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | The assessment has been revised and the individual's ability to swim has been noted. A copy of this notation will be submitted via email. In the future, the Program Supervisor will ensure that the annual assessment is fully completed, including the individual's knowledge of water safety and ability to swim. This item is also part of the Supervisor's Quarterly Inspection, which will be submitted via email. |
12/05/2014
| Implemented |
| 6500.182(c)(1)(vi) | Individual #1's record did not include a current, dated photograph. | Each individual's record must include the following information: Personal information, including: A current, dated photograph. | A current dated photograph of the consumer has been placed in the consumer's record. A copy of this dated photo will be submitted via email. The program Supervisor will monitor all records on a quarterly basis to ensure that current dated photographs are in all records. |
12/05/2014
| Implemented |