Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | Individual #1's bathroom and bedroom smelled strongly of urine. | Clean and sanitary conditions shall be maintained in the home. | The individual residing in the apartment of this home has unique needs and routines which limit the ability for staff to remove soiled clothing or linens and launder them in a more timely manner. The Program Specialist and staff will continue to work with the individual¿s Behavior Support Specialist and the rest of his team to create ways to encourage that this is happening in a timelier manner. His team will continue to attempt and analyze ways to dissipate the unfavorable odor in the apartment. Staff will open the window a crack to allow for air flow as long as it is tolerated by the individual. Staff will continue to clean his apartment with a variety of cleaners in an attempt to eliminate the unfavorable odor of urine. An air purifier has been purchased and placed in the apartment. See attachment #40
Program Managers were trained on this requirement. See attachment #2. Supervisors will be trained on this requirement on 12/13/17. see attachment #3. |
12/13/2017
| Implemented |
6400.64(e) | The trash receptacle in the hallway before entering into Individual #1's apartment was over 18 inches tall and did not have a lid. | Trash receptacles over 18 inches high shall have lids. | The trash receptacle was replaced. See attachment # 41
Residential Program Mangers have reviewed this regulation and understand that trash receptacle height should be monitored and those over 18 inches are required to have a lid (attachment #2). Residential Supervisors will review this regulation at the monthly Residential Supervisor meeting on 12/13/17 (attachment #3). |
12/13/2017
| Implemented |
6400.68(b) | Repeat 10/05/16: The water temperature of the bathtub in the full bathroom on the main living floor measured 125.1 °F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | A metering valve has been placed on the hot water heater. The water temperature has been tested several times since the valve has been in place and has not gone above 120 degrees F. See Attachment # 39
Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). Program Specialists monitor the water temperature at each home on a monthly basis. |
12/13/2017
| Implemented |
6400.101 | Individual #1 was asleep in his/her recliner in the living room with the chair reclined. The foot rest of the recliner was blocking the exit leading out of the living room to the back yard. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Staff attempted to move the recliner further away from the exit so that the footrest would not block the exit when it was in use. Unfortunately, the individual will not allow for the recliner to be moved. He moves it back to the place where he prefers it. When the individual is not utilizing the footrest, the chair does not block the exit. The Program Specialist and staff will continue to work with his Behavioral Support Specialist and team to attempt creative ways to place the chair in an effort for the individual to allow for the change. Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). |
12/13/2017
| Implemented |
6400.104 | The fire notification letter dated 2/11/16 stated that all individuals are capable of evacuating during a fire drill within two and half minutes. However Individual #1 requires assistance to evacuate as he/she will not evacuate independently and Individual #2 utilizes a bed shaker. | 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.
| All Program Managers have been trained on this regulation and understand that the letter to the fire company must state the specific evacuation needs for each individual residing in the home (attachment # 2). The Program Managers have completed an audit of the fire letters for each home and have sent updated letters to the fire companies with specific evacuation needs for each individual (verbal prompts, ambulatory but uses a walker, non-ambulatory, refusals to evacuate, etc.). Residential Supervisors will be re-trained on this regulation at the Supervisors meeting on 12/13/17 (attachment #3). See Attachment # 36, which is the updated letter to the fire department for the Boundary Avenue home. |
12/13/2017
| Implemented |
6400.112(h) | Repeat 10/05/16: Individual #1 did not evacuate during any of the fire drills conducted from 10/01/2016 to 10/31/2017. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Individual #1 refuses to evacuate for fire drills. This has been indicated in the updated fire letter sent to the fire department (attachment # 36). He does have a plan in place regarding his refusal to evacuate the home during fire drills. See attachment # 37
During the licensing of this home, it was brought to our attention that Penn-Mar must request a waiver of regulation for him to continue residing in his current placement. This waiver request was submitted on November 21, 2017. See attachment #38
The Program Specialist and staff will continue to work with his Behavior Support Specialist to create ways to attempt assisting him to comply with evaluating during fire drills.
Program Managers have reviewed and understand this regulation (attachment #2). Residential Supervisor will review this regulation during the Supervisor meeting on 12/13/17 (attachment # 3). |
12/13/2017
| Implemented |
6400.195(a) | Individual #1 did not have toilet paper and soap available to him/her in the bathroom due to behavioral concerns. Individual#1 has a behavior support plan but there are no restrictive procedures currently in place. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| Staff give Individual #1 toilet paper as he needs it in an attempt to keep the toilet from clogging every time he uses the bathroom. When he has a roll of toilet paper, he attempts to flush the entire roll down the toilet, thus clogging the toilet.
Program Specialists have reviewed this regulation and understand the procedure for restrictive plans (attachment #2). The Residential Supervisors will review this regulation at the Residential Supervisor meeting on 12/13/17 (attachment #3).
The Program Specialist has written a restrictive plan for the toilet paper not being kept in his bathroom that will be reviewed by our Quality Assurance team on 12/21/17. See attachment # 35 |
12/13/2017
| Implemented |