| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(c) | Staff #1 had 15.25 hours of human services training for the annual training year of 5/1/2011 to 4/30/2012. Partially Implemented- Adequate Progress LM 2/26/2013 | (c) Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | A new policy was written to include requirement of 24 hours of training. The yearly training summary sheet listing all trainings for each employee was also amended to indicate the need for 24 hours of training. The site supervisor is responsible for assuring each employee completes the necessary training. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. |
02/21/2013
| Implemented |
| 2380.84 | A fire safety inspection occurred on 5/1/2012, however; the fire safety inspection for 2011 was unavailable for review. Fully Implemented LM 02/26/2013 | The facility shall have an annual onsite firesafety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept. | The fire safety inspection policy was updated to assure the annual on site fire safety inspection is completed within one year of the previous inspection. The inspection for the 2013 year was completed on 1/29/2013 which is within one year of the inspection on 5/1/2012. These records are maintained within the site. The site supervisor is responsible for assuring these inspections are completed on time and for maintaining records within the center. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. |
02/21/2013
| Implemented |
| 2380.89(a) | The facility did not conduct unannounced fire drills during the months of July 2012, June 2012, April 2012, March 2012, January 2012, and December 2011. | (a) An unannounced fire drill shall be held at least once a month. | The policy regarding scheduling fire drills was amended to clarify the need for monthly fire drills. A form with a list of all the months is used to record the fire drills as a way to ensure a fire drill is held monthly. The site supervisor is responsible for assuring monthly fire drills are held. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. Three consecutive months of fire drills were completed to demonstrate compliance. Partially Implemented LM 3-7-13 |
02/21/2013
| Implemented |
| 2380.89(d) | The evacuation time for a fire drill held on 8/29/2012 was documented as 3 minutes and 25 seconds. Partially Implemented- Adequate Progress LM 2/26/2013 | (d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employee of the facility or of the legal entity of the facility. | A fire safety inspection was completed on 1/29/13 and the fire safety expert provided a letter indicating the evacuation time cannot exceed seven minutes. The fire drill record was amended to specify the new maximum evacuation time. The site supervisor is responsible for assuring members evacuate within the required time and assuring a fire safety inspector indicates, in writing, the seven minute evacuation time every year. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. |
02/21/2013
| Implemented |
| 2380.111(c)(3) | Individual #2's physical examination, dated 9/6/2012, had no record of immunizations. | (c) The physical examination shall include:(3) Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The policy related to member physicals was amended to include the requirement for members to have diptheria and tetanus immunizations at least once every ten years. The client medical record was changed to include this requirement. The site nurse is responsible for assuring the immunizations were recorded on the annual physical examination. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. Partially Implemented 3-7-13 LM |
02/21/2013
| Implemented |
| 2380.111(c)(4) | Individual #2 did not have a hearing screening annually. The last hearing screening, in the record, was dated 10/14/2011. | (c) The physical examination shall include:(4) Vision and hearing screening, as recommended by the physician. | The policy related to member physicals was amended to include the requirement for members to have an annual hearing screening. The client medical record includes a specific area for physicians to record the results. The nurse completed the hearing screening for individual #2 on 11/15/2012. The annual nursing assessment also includes a section to assess members¿ hearing. The site nurse is responsible for completing a yearly hearing assessment and assuring the physician completes a sensory assessment every year. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. A hearing screening completed within the annual requirement was submitted. Fully Implemented 3-7-13 LM |
02/21/2013
| Implemented |
| 2380.181(a) | Individual #1 did not have an assessment completed within 60 calendar days after the admission date of 8/13/2012. The record contained no assessment. | (a) Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | A policy was created to ensure an initial and yearly assessment is completed. An assessment form was created to address the required areas. The nurse completed the assessment for individual #1 on 11/15/2012. The site nurse/program specialist is responsible for ensuring the assessments are completed. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. An annual assessment was attached to demonstrate compliance. Fully Implemented 3-7-13 LM |
02/21/2013
| Implemented |
| 2380.186(a) | There are no documented three month ISP reviews in the record of Individual #2. | (a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP. | A policy was created to ensure ISPs are reviewed every three months. An assessment form was created to address the required areas of review. The nurse completed the assessment for individual #2 on 11/15/2012. The site nurse/program specialist is responsible for ensuring the assessments are completed. All staff was instructed on the requirements and changes in policy and paperwork on 11/13/2012. ISP 3 month review is referred to as an "assessment" in the plan of correction. Completed three month review was attached to demonstrate compliance. Fully Implemented 3-7-13 LM |
02/21/2013
| Implemented |