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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit did not contain tweezers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On 9/20/17, the tweezers were returned to the first aid kit. They had been removed from the first aid box and staff had taken them and placed in the van. they were placed back in on their return. An SComm on the therap system was sent out to all staff on 10/6/17 by Stacey Cannon, the program director directing all staff that all first aid items are to remain in the first aid kit unless being used for an immediate medical/first aid need. Items are to be replaced/replenished as soon as the need for the first aid item has been taken care of. If staff need to have an item replenished they will contact the Health Services Coordinator immediately so that the kit can be restocked. All House supervisors are to continue to check to ensure all items are in the first aid box during their weekly home inspection visit and refer to the checklist on their home inspection visit form that lists all required items in first aid box and report any needs to the Health Services Coordinator so that items can be restocked immediately by the Health Services Coordinator. Ca thy Proctor APD will review procedures with supervisors on 10/19/17. Supervisors will review procedures at the next monthly staff meeting. Copy of home visit form and SComm emailed to [Human Services Licensing Supervisor] on 10/18/17 |
09/20/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.213(1)(i) | Individual #1's record did not indicate color of hair, color of eyes or identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | On 10-9-14, a Face Sheet has been created that will be completed during admission and updated on an annual basis. The Face sheet includes color of hair, color of eyes or identifying marks. Please see supporting documentation. [All individuals' records will be audited to ensure personal information is in the records. (AS 10-17-14)] |
10/17/2014
| Implemented |
| 6400.216(a) | Individual #2's record was on a shelf in an unlocked office. | An individual's records shall be kept locked when unattended. | All dFs staff will continue to receive HIPPA/Compliance training on an annual basis. This training is conducted by the dFs Privacy Officer. Per dFs Policy and Procedure, Management of Confidential Information, if a security incident occurred, staff will continue to fill out the Security Incident Report. Please see supporting documentation. All dFs staff will continue to receive training during orientation that will cover "Confidentiality", "Let's Get Hip about HIPAA", "HIPPA Compliance, confidentiality", "HIPPA case studies", "Do's and Don'ts of HIPPA." Please see highlighted area on the supporting documentation. |
10/17/2014
| Implemented |
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