Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(c) | The dishwasher soap was not kept in it¿s original container. It was in a plastic jug. | Poisonous materials shall be stored in their original, labeled containers. | On 2/20/2015, unmarked dishwasher container was replaced with an orginail labeled container. each home will be inspected by the supervisor of that home to assure that all poisonous materials shall be stored in their orginal labeled containers. Utilizing care tracker, all team members will be trained on the necessity to assure that all poisonous materials are stored in their original labeled containers. |
| Implemented |
6400.103 | The written evacuation procedure does not contain the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Means of transportation was corrected on 5/11/2015 for the 348 westview drive home evacuation procedures. All homes will be verified by that supervisors to assure that means of transportation is noted on evacuation procedures. Copy of updated evacuation procedures for 348 westview drive home will be provided. Using care tracker each supervisor will verify that each home has evacuation procedures that includes means of transportation. |
| Implemented |
6400.141(c)(6) | Individual #1 had a TB test done on 8/3/12 and not again until 8/20/14. | 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. | All supervisors will be trained on the necessity of TB testing every 2 years. Record review of all individuals will be completed by the supervisors of each home to verify compliance with TB testing every two years and at least within the 15 day grace period and document that information. Utilizing care tracker, all supervisors will be trained on the necessity to complete TB testing every two years for each individual. |
| Implemented |
6400.187 | The Individual Support Plan (ISP) meeting for Individual #1 was on 9/11/14 and a copy of the ISP was not sent to team members until 11/6/14. | A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings.
| Record review of all individuals will be completed by the supervisors of each home to verify complaince of receipt of ISP within 30 days of ISP meeting, or documentation of request for such. Using care tracker, supervisors will be trained to request ISP within 30 days of ISP meeting and maintain documentation. |
| Implemented |