| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(1) | The program specialist did not complete Individual #1's assessment dated 7/11/16. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The Program Specialists will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16.
A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter.
An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. |
11/03/2016
| Implemented |
| 6400.112(c) | The written fire drill record did not include the exit route used for the fire drill conducted on 7/21/16. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 10/31/16 CEO met with Program Specialist on a violation of 6400.112( c).
A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route uses, problems encountered and whether the fire alarm or smoke detector was operative.
A new fire drill report was completed on 10/31/16. All areas of the fire drill form must be completed monthly and all areas completed, no blank sections are acceptable.
Beginning on 11/1/16 quality assessment checks on all monthly fire drills will be done. CEO and Program Specialist must sign and date each monthly fire drill report.
10/31/16 an in-service was completed with Program Specialist. The in-service included all of the above information. By 11/8/16, Program Specialist will have completed in-services with all residential supervisors.
On 11/16/16, a mandatory staff meeting will be held to discuss new fire drill documentation. In-service will be signed and dated by all staff members. |
11/03/2016
| Implemented |
| 6400.112(h) | The fire drills conducted on 1/15/16 and 7/21/16 did not indicate if the individuals met at the designated meeting place during the drill; therefore compliance could not be measured. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | A new fire drill report form completed on 10/31/16. All areas of fire drill form must be completed monthly and all areas completed, no blank sections are acceptable.
Beginning on 11/1/16 quality assessment checks on all fire drills will be completed each month. CEO and Program Specialist must sign and date each individual fire drill report.
On 10/31/16 an in-service conducted with Program Specialist was completed. In-service included all of the above.
By 11/8/16 a mandatory staff meeting will be held to discuss new fire drill documentation. In-service will be signed and dated by all staff in attendance. |
11/03/2016
| Implemented |
| 6400.141(c)(6) | Individual #1 had a Tuberculin skin test read on 12/12/12 and then again on 1/23/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | On 10/31/16 CEO met with Program Specialist to discuss 6400.141(c )(6). The Program Specialist will develop new calendars to track every 2 year physical requirements, including Tuberculin skin testing by Mantoux method with negative results. If Tuberculin skin test is positive, an initial chest x-ray with results noted.
An in-service occurred on 10/31/16 with all Program Specialists on the above requirement. Documentation of in-service done and signed and dated by all Program Specialists.
A quality assessment tool will be completed by Program Specialist and forwarded to CEO for review beginning on 11/1/16 and each month thereafter. |
11/03/2016
| Implemented |
| 6400.181(a) | Individual #1 had an assessment completed on 6/8/15 and then again on 7/11/16. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | CEO met with all Program Specialists on requirement 6400.181(a). Each individual must have an initial assessment within 1 year prior to or 60 calendar days after admission to our residential home and an updated annual assessment annually thereafter. The initial assessment must include assessments of adaptive behavior and level of skills completed within 6 months prior to admission to our residential homes.
A quality assessment tool on all new admissions will be completed to assure that all the above requirements have been met. This tool to begin 11/1/16 and will be forwarded to CEO for compliance.
In-service done by CEO on 10/31/16 with all Program Specialists. Documentation of in-service done, signed and dated by all Program Specialists. |
11/03/2016
| Implemented |
| 6400.181(d) | The program specialist did not sign and date Individual #1's assessment dated 7/11/16. | The program specialist shall sign and date the assessment. | The Program Specialists will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16.
A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter.
An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. |
11/03/2016
| Implemented |