| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Surfaces in good repair- There are 3 white ceiling tiles in the ceiling in the hall way above the down stairs bathroom that have large water stains- approx. 4x4 size brown stains. These are old stains according to the provider. | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediate:
Friendship Community shall replace the water stained ceiling tiles on or before 8/31/19.
Global Immediate:
All Program Managers will complete a physical site walk through and compile a list of any surface areas of needed repair/replacement in the home and a list shall be sent to the Friendship Community Maintenance Team by 8/31/19.
Director of Operations provided retraining to Program Managers, Program Coordinators and the Associate Director of Facility Services on 8/15/19 regarding the necessity for recognition and completion of repairs to all surfaces within 6400 settings within a timely manner.
Global Preventative:
Associate Director of Facility Services, Associate Directors of Operations and/or Director of Operations shall perform routine walk-through inspections of each home in regards to physical site requirements and Associate Director of Facility Services shall ensure that all repairs are completed within a timely manner by monitoring the Maintenance Team task completion via the Trac system.
All training/retraining documentation shall be kept on file, as well as all notes recorded during walk-through inspections and follow-up completion of each task within the Trac system. |
08/31/2019
| Implemented |
| 6400.71 | Emergency phone numbers- There was no emergency phone numbers on or by the cordless- hand held telephones in the Livingroom and in the upstairs office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Immediate:
Emergency Numbers, including the nearest hospital, were immediately placed on the phone in all locations where a phone is present within the home on 8/15/19 by the Program Manager.
Global Immediate:
Program Managers and Program Coordinators received retraining by the Director of Operations on 8/15/19 regarding the necessity to have all emergency numbers, including the nearest hospital, located on or near each phone in the home.
Program Managers shall verify all required Emergency Numbers are located either on or near every phone within their program. Verification of this review shall be sent to the Associate Directors of Operations by 8/31/19. Any occurrences of phones missing any of the Emergency Numbers shall be rectified immediately upon discovery.
Global Preventative:
A standardized template for each program shall be developed that contains all necessary information/phone numbers by Operations Leadership. This shall be developed by 8/31/19 and distributed to every 6400 program.
Program Coordinators shall receive retraining on the necessity to verify during their monthly monitoring that all emergency numbers are present on or by every phone within the program. This retraining shall be provided by the Associate Directors of Operations on or before 8/31/19.
All training/retraining documentation shall be kept on file. |
08/31/2019
| Implemented |
| 6400.112(a) | An unannounced fire drill was not held during the month of May 2019 | An unannounced fire drill shall be held at least once a month. | Immediate:
The Program Manager received immediate retraining on the need to complete successful unannounced fire drills once monthly on 8/15/19. Successful monthly drills have been documented since the violation occurred in May 2019, demonstrating a pattern of compliance.
Global Immediate:
All Program Managers and Program Coordinators received retraining on 8/15/19 by the Director of Operations regarding the requirement to complete successful unannounced fire drills once monthly.
Global Preventative:
Beginning in September 2019, Associate Directors of Operations shall review each Programs¿ Monthly Fire Drill records for 6 months, to end February 2020, to ensure all fire drills have been successfully completed within the designated evacuation time frame.
Friendship Community procedure shall be updated to require all fire drills in 6400 programs be completed within the first 3 weeks of each calendar month. Retraining on this requirement shall be completed by Associate Directors of Operations by 8/31/19.
Documentation of all training shall be kept on file. |
08/31/2019
| Implemented |
| 6400.113(a) | Individual # 1 had fire safety training on 2/13/19 in relation to this current home. However she moved into the home on 12/6/18 and did not receive fire safety training upon admission to her new home. She had previous fire safety training from a different home on 5/2/18. Individuals # 2, #3 and #4 had fire safety training on 5/3/17 and not again until 8/19/18; outside the annual time frame requirement. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Immediate:
The Program Manager received retraining on 8/15/19 regarding the requirement for Individual Fire Safety training to occur upon admission to a home and on an annual basis.
Global Immediate:
All Program Managers and Program Coordinators received retraining on 8/15/19 by the Director of Operations regarding the requirement for Individual Fire Safety training to occur upon admission to a home and on an annual basis for each Individual.
Global Preventative:
Friendship Community shall adjust the organization¿s policy to conduct Individual fire safety training semi-annually, to occur in April and October for each Individual within a 6400 program, regardless of the date of their initial fire safety training.
Friendship Community shall review and adjust the Monthly Fire Drill Record Template to include a review of when the most recent Individual Fire Safety Training occurred. This review and adjustment shall be completed by the Operations Leadership Team and completed by 8/31/19, with retraining being provided to the Program Manager and Program Coordinator Team on or before 8/31/19, with implementation of the adjusted template in September 2019.
All training/retraining documentation shall be kept on file. |
08/31/2019
| Implemented |