| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The emergency evacuation plans for Individuals #1 and 2 do not include the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Program Managers were trained on regulation 6400.103 by the Director of Quality Assurance and Training on 03/09/21. The outline and attendance record are submitted for review (#1). The Emergency Evacuation Plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individual #1 & #2 forms have been submitted for review (#1). Program Managers were instructed to review each person we serves emergency evacuation plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 3/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/11/2021
| Implemented |
| 6400.104 | The 2/20/20 notification letter states "During our monthly fire drills, Individual located in bedroom [number] requires verbal prompting to leave the home on occasion". The notification letter does not specify which individual needs prompting, nor where that Individuals bedroom is. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Managers were trained on regulation 6400.104 by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance record are submitted for review (#2). The CLAs fire department letter has been submitted for review. Program Managers were instructed to review each homes fire department letter for accurate information, location, and home map marked with exact location of each person served. All homes are to submit the updated letter and map to the Program Specialist prior to 03/09/21. Program Specialists are required to email the Operations Directors by 03/12/21 with the completion of the task. To ensure no further infractions occur, the Program Manager will send any updated letter to the Program Specialist for review, as needed. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/11/2021
| Implemented |
| 6400.145(3) | Individual #3's Emergency Medical Plan's staffing plan states, in part, that staff should contact the emergency on call system. The number to call reads "724/XXX-XXXX", which is not a working telephone number. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on 03/09/21. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individual #3 form have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/11/2021
| Implemented |