| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(i) | Staff #4 completed first aid training on 1/26/11 and not again until 3/26/13. | 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. | Staff #4 is currently certified and will complete first aid training by January 31, 2015.
In conjunction with the LCN Region Directed Corrective Action Plan Hope Training Department will be tracking all staff training in a computer database. Memorandums will be sent to staff as reminders of upcoming training. Memorandums will also be sent to Directors of their staffs' training dates and attendance at the training.
CMSU Region currently has a procedure for tracking training in place and will maintain the current practice. |
02/28/2015
| Implemented |
| 6400.72(b) | The patio screen door had a tear in the screen near the bottom left-hand corner (looking at the screen from the outside of the house). | Screens, windows and doors shall be in good repair. | The screen in the patio door was repaired. See attachments #2, #3, #4.
In conjunction with the LCN Region Directed Corrective Action Plan to assure continued compliance, Hope has hired a Residential Support Specialist that will oversee the maintenance department. The RSS will inspect each community home once a month, using a checklist of all physical site regulations to assure the homes are properly maintained. The checklist will be reviewed by the Residential Coordinator each month. The RSS will assign maintenance issues to be completed by maintenance staff within two weeks. Directors will also visit other Director's home once a month and complete a physical site checklist. All issues will be referred to the RSS for assignment.
CMSU Region currently has a process for repairs in place and will maintain the current practice. |
11/14/2014
| Implemented |
| 6400.103 | There was not an emergency evactuation procedure for this location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| An emergency evacuation procedure was written for 1609 Northway Apt. 2 which includes individual and staff responsibilities, means of transportation, and emergency shelter location. See attachment #1. Residential staff will review the evacuation plan with the program director at the bi-weekly staff meeting. The emergency evacuation procedure will be maintained in the control log in each home. The emergency evacuation procedure will be updated as changes occur and annually during fire safety by the program director and submitted to RSS for review. CMSU Region currently has an emergency evacuation procedure process in place and will maintain the current practice. |
02/28/2015
| Implemented |