2380.89(c) | The written fire drill record for the fire drill held 12-06-16 did not include the amount of time it took for evacuation. | 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 was operative. | The Executive Director reviewed the Fire Drill log and updated the form to include an area for staff initials. Staff initials must be of someone other than the program specialist who conducted the fire drill. These initials will signify that the form was reviewed for completeness and accuracy. To prevent future non-compliance, all fire drill logs will be submitted to the Executive Director for review on a monthly basis to ensure all information is complete. The program specialist received training regarding completion of fire drills and tracking process by the Executive Director on February 10, 2017. A copy of the Fire Drill Log and training log will be attached as Attachment #2. |
02/11/2017
| Implemented |
2380.186(d) | The program specialist did not provide Individual #1's 3 month ISP reviews ending on 12-2-16, 9-6-16, 6-9-16 and 3-4-16 to the plan team members. The program specialist did not provide Individual #2's 3 month ISP reviews ending on 11-2-16, 8-16-16, 5-19-16 to the plan team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | As of February 10, 2017 the ISP review material for individuals #1 and #2 will be distributed to the teams of each individual, even though they are late. As of February 10, 2017 a review of client records will be completed by the program specialist ensuring that distribution information is up to date for every individual in program. In order to prevent future non-compliance, retraining will be provided on the regulation and expectations surrounding the ISP process. The training will be provided to the program specialist by the Executive Director - this will be completed by February 10, 2017. Quarterly, a compliance audit will be completed by Human Resources and a random sample of client files will be reviewed to ensure that all records are up-to-date and all information is included per regulations. A copy of the training log, quarterly review invitation, review letter, and quarterly review template will be attached as Attachment #1. |
02/11/2017
| Implemented |