Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | There was poisons unlocked under the kitchen sink(clorox bleach, clorox wipes, comet cleaner) and individual is to have all posions locked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials were removed from the under sink cabinet and placed in a locked storage closet on the first floor. The Training Supervisor met with all the staff on 9-3-15 to educate them on the need to lock all poisons. Attachment 14: FOT Training Record Attachment # 15 a under sink with cleaners, 15 b under sink empty, 15 c: Moved to locked cabinet. |
09/09/2015
| Implemented |
6400.112(e) | A fire drill during sleeping hours was held on 7/18/14 and then again on 2/28/15. | A fire drill shall be held during sleeping hours at least every 6 months. | The Supervisor of the home held a Sleep Fire Drill on 7-31-2015 to meet the 6 month sleep drill requirements. Attachment 11: Fire Drill 7-31-15. To assure that the Supervisor continues to meet the sleep drill requirements the Mattern House Secretary has been educated to understand our responsibilities and to assist the Supervisors in maintaining the required schedule. Attachment 12: Training Record. We have also changed the Fire Drill Form to better assist staff in completing fire drills and identifying any problems that occur during a drill. Attachment 13: 8-31-15 Fire Drill with updated format. |
09/09/2015
| Implemented |
6400.181(e)(13)(i) | Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Program Specialist has updated Individual #2's assessment to include the progress over the last 365 days and current days and current levels in health. Attachment 9: Ind #2 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 10: Ind. #2 Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5: Training Log |
09/09/2015
| Implemented |
6400.181(e)(13)(v) | Individual #1's assessment did not include the progress over the last 365 calendar days and current days and current levels in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Program Specialist has updated Individual #2's assessment to include the progress over the last 365 days and current days and current levels in socialization. Attachment 9: Ind #2 Assessment dated 9/8/15. The new updated assessment has been provided to the team . Attachment 10: Ind. #2 Assessment Team Letter. The Program Specialist has received training on the required Assessment content to prevent this issue from occurring again. Attachment 5: Training Log |
09/08/2015
| Implemented |
6400.183(5) | Individual #1's ISP did not include a SEEN Plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Individual #2 has a SEEN plan, the support coordinator was provided a copy of the SEEN Plan but did not enter the information on the ISP. The Program Specialist has notified the Support Coordinator of the presence of the SEEN Plan and requested an addition / correction of the ISP. Attachment 8: Letter to SC requesting addition of info to ISP |
09/09/2015
| Implemented |