| 6400.112(d) | The fire drill held on 03/31/20 had an evacuation time of 2 minutes and 35 seconds. The home does not have an extend evacuation time. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Again, this violation was unable to be corrected. Fire drill documentation was reviewed for all drills prior to, and after, the March drill to determine if there was an ongoing issue with evacuation times. All other drills were compliant and continue monthly. Each "record of fire drill" completed has a section for two supervisory initials. One is for the supervisor responsible for conducting the drill. The other initial is from the supervisor in the office reviewing the drill for compliance. A training was held on 9/23/20 to review regulation 112 (d) and remind supervisory staff that if they have an evacuation time over 2min30sec, they will need to repeat the drill at another time that month. All supervisors were reminded to review those drills for compliance prior to submitting and filing them. |
09/23/2020
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat symptoms of generalized anxiety disorder (GAD) and major depression. The review completed on 03/05/2020 did not include the current medications and necessary dosages. The review completed on 06/09/2020 did not include the reason for prescribing the medications and the need to continue the medications. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | This violation was unable to be corrected. The missing and updated information has been documented in individual #1's file. Our "medication monitoring" form was created to meet all regulatory requirements, when completed in it entirety. Staff were trained on 9/23/20. The regulation 165 (g) was reviewed and they were instructed to be sure that all sections of the "medication monitoring" form are filled out prior to leaving the doctors office. The program supervisors and program specialist were reminded not to copy or submit the form to the individuals file without all sections being completed. [Documentation of the audits by the supervisors and PS shall be kept. (DPOC by AES,HSLS on 9/28/20)] |
09/23/2020
| Implemented |