| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | Staff #4 was not trained in job responsibilties, the daily operation of the home. Staff #3 was not trained in the daily operation of the home. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #23). New Hire Residence Orientation for Staff #4 shows that she was trained in her job responsibilities prior to working with individuals (Attachment #24). New Hire Residence Orientation for a staff hired since licensing shows that she was trained prior to working with individuals (Attachment #25). House Managers will provide all training documentation to the Program Manager for review instead of turning in directly to human resources. |
04/22/2015
| Implemented |
| 6400.46(i) | Staff #4 did not receive CPR within 6 months after the day of initial employment. Her hire date was 3/25/14 and she had CPR on 10.9/14. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #26). Only 3 staff have been hired since licensing, all started in May but have been scheduled for the July 2nd CPR training. Will forward certification when received. |
07/31/2015
| Implemented |
| 6400.112(c) | The fire drill log from 5/7/14 did not include if the alarms were operable. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #21) Fire Drill records completed since 1/29/2015 to include if the alarms were operable is attached (Attachment 22 ¿ 22k). |
04/22/2015
| Implemented |
| 6400.151(c)(2) | Staff #5's tuberculin skin test was completed on 8/21/11 and then again on 6/14/14. | 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 regulation was reviewed with the Program Manager and House Managers on 4/29/2015 by the Assistant Director (Attachment #14). The agency is implementing ADP Workforce portal on 6/22/2015 that will allow Program Specialists to track staff physical and TB test dates and send messages when they are due. A previous and current staff physical is included to show that staff are getting TB testing done within the required timeframes (Attachment # 15 & #16). |
06/22/2015
| Implemented |
| 6400.151(c)(3) | Staff #4 and staff #5's phyical did not include communicable disease status. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #17). The physicals for staff 4 & 5 were returned to their doctors office for completion which occurred on 2/18/2015 and 2/20/2015 (Attachment #18 & #19). The Assistant Director also notified all House Managers, Program Supervisors and Program Managers that all new hire physicals and criminal background checks must be approved before new employee can attend new hire orientation (Attachment #20). |
04/22/2015
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #12). The lifetime medical history was added to Individual #1¿s assessment (Attachment #13a-y). Program Manager will review assessments for all Community Home Services program participants and insure that lifetime medical histories are attached to the assessment, not just as part of the overall consumer file. |
04/22/2015
| Implemented |
| 6400.186(b) | Individual #1's ISP reviews where not signed for 12/16/14 and 9/11/14. The program specialist did not sign the ISP review on 12/16/14. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The regulation was reviewed with the Program Manager and House Managers on 4/22/2015 by the Assistant Director (Attachment #9). ISP reviews for Individual #1 and another consumer completed since licensing are attached (Attachment # 10 & #11). Program Manager will insure that all ISP reviews for all Community Home Services participants are signed and dated by the individual and by the Program Specialist/Manager. |
04/29/2015
| Implemented |