| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed on 8/20/15; the agency's current certificate of compliance is from 9/1/15 to 9/1/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Office Coordinator has an event scheduled in her Outlook calendar starting in March where she can send out the self-assessments that will then be due by April 31. The ID/D Manager will track when they are received to ensure they are completed in a timely manner. |
03/26/2016
| Implemented |
| 6400.106 | The furnace was inspected on 9/9/14 and then again on 10/26/15. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Office Coordinator set up a tracking spreadsheet to ensure the Facilities Department schedules furnace inspections in a timely manner. The tracking will be monitored by the Office Coordinator and Secretary and the scheduling will be sent out to the Facilities department 1 month ahead of the due date.[Immediately, the ID/D Manager will develop, implement, train staff and oversee a procedures to ensure all furnaces at all community homes are inspected and cleaned at least annually by a professional furnace cleaning company, procedures shall include a review of the written documentation and a system to ensure written documentation of the inspection and cleaning is kept and available for review and tracking. (AS 4/20/16)] |
03/26/2016
| Implemented |
| 6400.151(a) | Direct Service Worker #1 had a physical examination completed on 1/10/13 and then again on 2/4/15. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The ID/D Residential Secretary will now send reminder letters for Physicals and TB directly to the DSP¿s home giving them a 2 month advance notice of their due date. She will also inform the Supervisor and Lead DSP at the sites so they can verbally remind DSP¿s of their due dates. The physicals will be received by the Supervisor and then sent to the Secretary to be tracked and filed. [Immediately, the ID/D Residential Director will develop, implement and train involved staff of a tracking system to ensure timely completion of staff physical examinations. At least quarterly, the ID/D Residential Director will review the tracking system and a 25% sample of aforementioned reminders and tracked physical examinations to ensure all staff person's required physical examinations are completed timely. Documentation of reviews, trainings and tracking shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1 had a Tuberculin test completed on 1/10/13 and then again on 2/4/15. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The ID/D Residential Secretary will now send reminder letters for Physicals and TB directly to the DSP¿s home giving them a 2 month advance notice of their due date. She will also inform the Supervisor and Lead DSP at the sites so they can verbally remind DSP¿s of their due dates. The physicals will be received by the Supervisor and then sent to the Secretary to be tracked and filed.[Immediately, the ID/D Residential Director will develop, implement and train involved staff of a tracking system to ensure timely completion of staff physical examinations including Tuberculin skin testing. At least quarterly, the ID/D Residential Director will review the tracking system and a 25% sample of aforementioned reminders and tracked physical examinations including Tuberculin skin testing to ensure all staff person's required physical examinations including Tuberculin skin testing are completed timely. Documentation of reviews, trainings and tracking shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |