| 6400.112(a) | An unannounced fire drill was not held in August 2018, September 2018 and October 2018. | An unannounced fire drill shall be held at least once a month. | All fire drills for this home have been completed and are up to date. Supporting documentation was reviewed during the inspection for fire drills held on November 2018 - March 2019. Will resend fire drill documents if needed. MCAR residential group home fire drills will be scheduled by the case managers. The Case Managers will schedule a fire drill for each home they supervise for the entire year. Residential direct care worker who is working in the home on the scheduled fire drill day will e notified by the case manager that a fire drill is to be completed that day. Residential direct care worker will conduct the fire drill. After the drill is complete they will contact the case manager to inform of the completed drill. Case manager will complete the fire drill log based on the information provided by the direct care staff and save on file for inspection. Protech security monitors all MCAR group home fire alarms. Residential Director will recieve quarterly reports from ProTech showing the dates and time fire drills were completed in each group home. [Prior to conducting fire drill or other aforementioned responsibilities regarding fire drills or within one month of receipt of the plan of correction/LIS, the CEO or designee shall educate all staff persons responsible for conducting and documenting fire drills and reviewing written fire drill records and aforementioned quarterly reports; of the requirements of conducting and documenting fire drills and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 9/9/19)] |
07/11/2019
| Implemented |
| 6400.141(a) | Individual #1, date of admission 4/15/19 did not have complete physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | MCAR Residential Director will provide individuals with the MCAR physical form upon acceptance into the Residential program. After Residential Director receives the referral from SC, Residential Director will email a copy of the MCAR physical form to the SC for the individual to have completed before starting services. Once MCAR Residential Director receives the physical form it will be reviewed by Nursing Director and Residential Director to ensure all areas of the form are filled out entirely. Next the Residential Director will forward a copy to the case manager for the that individual. The case manager will schedule the annual physical for that individual and set reminders for annual physicals to be completed in there outlook calendar. An updated physical has been completed for this individual in question and supporting documentation will be email. [Individual #1 had a physical examination completed 4/26/19. The physical examination is not completed with required information. Immediately, the CEO or designee shall follow up with the physician to ensure all required information is completed and Individual #1's health services are provided arranged. Immediately and upon competition of all individuals' current physical examination, a designated staff person who is educated in the requirements of Individual physical examination requirements and the agency's procedures for following up on physician's orders, shall audit all individuals' physical examinations to ensure all required areas are addressed and follow up completed to ensure all individuals' health needs are arranged and provided for. Documentation of audits, follow up arrangements and trainings shall be kept. (DPOC by AES,HSLS on 9/9/2019)] |
07/11/2019
| Implemented |