| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | REPEAT from 7/23/15- Three large containers of Clorox, three 40oz. containers of Windex, 15 bottles of shampoo and conditioner, Soft Soap, Bleach, Arm and Hammer Laundry detergent, Shout cleaner, and 5 gallons of paint were unlocked and accessible in the basement. Individuals #1 and #2 were not safe around poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The laundry room was not locked because the area was previously used as office space. The room is now used for parties and get togethers and as such, needs to be locked. The door has been provided with a digital lock to prevent unauthorized access.(ATTACHMENT: RR-12 ) The laundry room door now has a digital lock which requires a 4 digit code. All staff including maintenance will be / have been educated on the need to assure that hazardous materials be secure when persons who cannot identify poisons may be present. (ATTACHMENT: T-1A ,1B; T-2A, 2B |
12/13/2016
| Implemented |
| 6400.66 | The outside lightbulb to the right of the front door did not function. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| IMMEDIATE FIX: On 7/25/2016 The light bulb was replaced( ATTACHEMENT: RR-11).Future Prevention: The Supervisors and Maintenance have been / will be educated on Chapter 6400.66 - adequate lighting and are responsible for alerting maintenance of any safety needs. ATTACHMENT: T-1A, T-1B ( TRAINING FOR ALL STAFF: & T-2A, T-2B (TRAINING FOR MAINTENANCE) . |
12/13/2016
| Implemented |
| 6400.68(c) | The quarterly coliform water tests conducted on 9/3/15 and 1/4/16 were not completed within the 3-month time periods. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The 3 month Coliform test is an important health measure to assure the consumpsion of safe water. Maintenance was unable to explain why tests had been completed every three months as per the regulation but December's test; not completed until January, then resumed the 3 month schedule as per the regulation. The Administrative Assistance has added Water tests reminders to her Outlook and developed a new process to assure it is completed along with water temperature tests. ( ATTACHMENT: RR-13) The Maintenance staff is responsible for timely completion of the test and have been trained in their responsibiltiy to meet the regulations.. ATTACHMENT: T-1A, T-1B. |
12/13/2016
| Implemented |
| 6400.71 | The emergency telephone numbers were not posted on or near the phone in the basement. The emergency numbers for the nearest hospital, police, fire department, and ambulance were not posted on or near the phone in the staff bedroom upstairs. | 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.
| The area was formerly office space and when the office moved out the staff bedroom was created. At that time House Supervisor failed to place Emergency Numbers with their portable phone. It is important to have emerency numbers located at all phones to assure appropraite personnel are reached. Fix: On 07/25/2016 An Emergency Phone List (ATTACHMENT: RR-9) was placed in the staff bedroom phone. ( ATTACHMENT: RR-10) All homes were provided notices of the importance of maintaining emergency numbers. (ATTACHMENT: RR-1) the House Supervisor is responsible to assure all Safety regulations are met in the home. The Program Specialist and Supervisors are trained in the importance of 6400.71 - Posting Emergency numbers. All staff will be / have been trained in their responsibilities. ATTACHEMENT: T-1A, T-1B. |
12/13/2016
| Implemented |
| 6400.104 | There was a notification letter sent to the fire department on 9/15/14 that did not include the exact location of the bedrooms of individuals who needed assistance evacuating in the event of a fire. Individuals #1, #2 and #3 required physical assistance to evacuate the home in the event of a fire. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Fix: On July 28, 2016 a completed floor plan was sent to the local fire department identifing the exact location of the individuals bedrooms. ATTACHMENT: RR-8A , RR-8B, RR-8C All home notifications to Fire Companies were reviewed to assure the standard has been met. The Program Specialist has been educated on the need for inclusion of a floor plan that identifies the locations of the person in the home and their level of need. ATTACHMENT: T-1A, T-1B. |
12/13/2016
| Implemented |
| 6400.112(e) | REPEAT from 7/23/15- From May 2015 until June 2016, only one fire drill was held during sleeping hours on 7/5/15. | A fire drill shall be held during sleeping hours at least every 6 months. | This violation occured because Sleep Drills were defined as occuring one hour after everyone was asleep. On 1-10-16 a drill held as 9:00 pm was disqualified.( ATTACHMENT: RR-4) We have adopted a new process for Fire Drills. (ATTACHMEnt: RR-5) Sleep Drills are defined as occuring between 11:00 pm to 6:00 am . The Administrative Assistant is responsible for sending out reminders. The Fire Drill form has been changed to reflect the new process which includes Sleep Drills every 5 months to assure compliance.( ATTACHEMNT: RR-6) Sleep Drill was held on 8/13/16 and will be held again in January 2017. ( ATTACHMENT RR-7 ) Staff have been / will be trained on the regulations to assure the safety of the people we support. (ATTACHMENT - T-1A, T-1B) |
12/13/2016
| Implemented |
| 6400.216(a) | An Individual¿s daily logs were stored in an unlocked location on the kitchen counter. The record information for many individuals was stored in an unlocked 3¿x3¿ moving box, sitting outside the home, under the back porch. | An individual's records shall be kept locked when unattended. | This error occured when staff were transporting documents to the office. Upon discovery the information was immediately secured.ATTACHMENT: RR-1. The Supervisors are responsible to assure that all documents are secured in envelopes and that they maintain possession of the information until it is secured at the destination. Second Error: This error occured during a move to new offices. The items were identified as needing destroyed during the move but maintenance never recieved the order. A Maintenance order was placed on 7/25/2016.( ATTACHMENT: RR-2 ) All documents were immediately secured upon discovery. Items have been destroyed / shredded at a N.A.I.D. comlpliant location.(ATTACHMENT: RR-3) Staff were trained on this regulations regarding all records being kept locked when unattended. Training is scheduled to occur over 4 opportunities to assure all staff understand their responsibilities. Training Dates: 11-23-16, 12-8-16, 12-9-16, & 12-13-16. ATTACHMENT: T-1A ( Staff Training Content List) T-1B (Signature Sheet dated 11/23/2016), T-2A, (Maintenance Training Content). T-2B - (Signature Sheet dated 12/8/2016) |
12/13/2006
| Implemented |