| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 was assessed to be unable to handle money independently. During the inspection, there was a jar of money ($5 bill and lots of change) unlocked and stored in a money counter/bank sitting on a cabinet in the staff office. The jar was labeled with Individual #1's name. The staff indicated that this money is not accounted for in the individual's daily financial log. The money jar indicated by the counter on the lid that $18 and change were in the jar but there wasn't that much in the jar. The counter lid was never reset after it was opened and there was no way to indicate how much money should have been in there for Individual #1. | (2) Disbursements made to or for the individual.
| Accurate accounty for all monies, including change, is important in order to assure that we are fiscally responsible for those persons who are dependent on staff for assistance. In an effort to promote independence Individual #1 is encoraged when in the community to make transactions with staff assistance and he likes to put the change in his bank. There is an LED counter on the top of the jar that had an amount indicated on it. The supervisor stated that that change jar is rarely used and has never used the LED to account for the money in the jar. The money was not totaled and included in Ind #1 petty cash account. The supervisor commented that she forgot it was even there and Ind #1 has not bothered with it in some time. She stated she has never reset or used the money counter feature on the bank therefore it was not reflective of the money contents amount. The supervisor totaled the money in the change and added it to Individual #1 petty cash. Attachment: # 44 Monthly Register Individual # 1) Supervisor have been educated to understand their need to recognize that all money amounts are important to keep track of. (Attachment: T-1 Supervisor Training) New processes have been developed by the client account manager. (Attachment: # 22 a-d Financial Process and training confirmation for all staff) The program specialist is responsible for assuring that the fiscal part of the assessment is accurate and that we promote any level of independence. The Program Specialist and House Supervisor is responsible for assuring that regulations are complied with. |
01/18/2019
| Implemented |
| 6400.66 | The exit from the sunporch located off the basement was not equipped with a light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| All exits need to be clearly lighted for safety. The area is an enclosed sun porch with an overhead light so maintenance felt the "exit" was lit because the enclosure was done with windows and the light from the overhead porch light was visible through the doorway outside. Maintenance have added a light at the rear exit. (Attachment: Photo of New Light outside the back door) Maintenance Staff have completed training on safety regulations. Attachment: T-3 Maintenance Training) Maintenance staff are responsible for checking each home monthly to assure the regulation is being met. The Program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.68(c) | The home is not connected to a public water system and the coliform water test was not completed every 3 months; water test completed 11/22/17 and not again until 3/5/18. | 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 testing of water in the home is to assure that it is staff for use by the people living there. The test was completed 11 days after its due date. The maintenance person offered no explaination why it was not completed and ultimately left this position . The current process is to complete the process every 60 days. The system is working for the current maintenance persons. All homes requiring coliform water tests were completed on 12/12/18. (Attachment: # 17 Completed Water Test. Results are reviewed by the Administrative Secretary . The Maintenance Staff has been educated on the need to maintain a strict schedule (Attachment: # T-3 Maintenance Training. The Maintenance Supervisor is responsible for assuring regulatory compliance. The Program Specialist is responsible for regulatory compliance as well. |
01/18/2019
| Implemented |
| 6400.103 | REPEAT from 8/29/17 renewal inspection: The written emergency evacuation procedure did not include the means of transportation and an emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| It is important to have a clear process identified in the event of an emergency to assure that care is provided, staff know exactly where they are to go without having to get direction from a supervisor. The current policy was written without a specific emergency shelter location in order to allow administration flexibilty in deciding an appropriate emergnecy shelter on a person by person basis according to their current needs . On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific emergency shelter location to be used. Attachment: # 42 Emergnecy Policy and Procedure. ) Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the method of transportation to be used. Attachment: T-1 Supervisor TRAining; Attachment T-2 Program Specialist / Medical Support Staff Training. All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. The program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.145(2) | The written emergency medical plan did not include the method of transportation to be used in a medical emergency. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | It is important to have a clear process identified in the event of an emergency to assure that care is provided. The current policy was written without a specific mode of transportation (any available) because vehicles frequently change at the homes. On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific vehicle to be used. Attachment: # 42 Emergnecy Policy and Procedure. ) Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the method of transportation to be used. Attachment: T-1 Supervisor TRAining; Attachment T-2 Program Specialist / Medical Support Staff Training. All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. The program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |