| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(c) | There was not a fire extinguisher in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The fire extinguisher will be moved from its present location to the kitchen on 07/24/2015. A picture and a copy of the invoice will be forwarded by 08/17/2015 as verification. [CEO or designee will complete a walk through of all homes and ensure there is a fire extinquisher in all kitchens of all home and in all required locations. (AS 10/1/15)] |
08/17/2015
| Implemented |
| 6400.112(d) | The fire drill completed on 10/12/14 at 8:00 AM had an evacuation time of 2 minutes 50 seconds. There is no written documentation extending the evacuation time from a fire safety expert. | 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. | When a completed fire drill has an unsuccessful evacuation time of more than 2 minutes 30 seconds, facility staff will immediately complete a second fire drill. The regulation requirement and agency fire drill procedure will be reviewed with facility staff by 08/17/2015. This group of individuals is ambulatory and have never had issues with evacuating within the required timeframe. This could have been a misprint. Facility staff will submit all fire drill forms to program supervisor Kim Johns within 48 hours for review and assessment should it become necessary to request a review by a fire safety expert on an extended evacuation time and to verify that the fire drill has a successful result. A copy of the procedure and training documents will be forwarded by 08/17/2015 as verification. |
08/17/2013
| Implemented |
| 6400.141(c)(6) | Individual #1's two most recent Tuberculin skin tests were completed on 9/17/12 and 10/5/14. | 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. | A checklist has been developed for the facility that program supervisor Kim Johns and program director Daren Rumbaugh will use weekly to verify that appointments have been scheduled and completed on time, to include TB testing. Program supervisor Kim Johns will train staff on the use of this form by 08/17/2015. The checklist and training documentation will be forwarded by 08/17/2015 as verification. |
08/17/2015
| Implemented |
| 6400.163(c) | Individual #1 had psychiatric medication reviews completed on 10/24/14 and 2/23/15. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Each time a psychiatric appointment is scheduled, cancelled or rescheduled, by the psychiatrist, the program supervisor Kim Johns and facility staff will verify that the appointment will occur within the three month time period between appointments. Program director Daren Rumbaugh will train the supervisor and facility staff on the corresponding regulation requirements and agency forms by 08/17/2015, and forward training documents by 08/17/2015 as verification. |
08/17/2015
| Implemented |
| 6400.181(f) | Individual #1's assessment, completed 8/8/14, was sent to the team on 10/23/13 for the 10/16/14 annual update ISP meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| A checklist was developed for program supervisor Kim Johns to track the ISP date and subsequent dates each component must be dated and sent to team members. Training will occur with the program supervisor and facility staff conducted by program director Daren Rumbaugh by 08/17/2015. The checklist will be used by the director and supervisor to verify assessment result letters/assessments are completed and sent at least 30 days prior to the ISP meeting, checking for typographical errors with the dates. The checklist and training verification will be forwarded by 08/17/2015 as verification. |
08/17/2015
| Implemented |