| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(c) | Staff #1 was hired on 11/6/2017. She does not have the qualifications required for this position. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | Staff qualifications will be obtained prior to start of employment or prior to promotion of a current employee
((Staff #1's credentials have been obtained and will be kept on file by the agency - CH 3/28/18)) |
03/09/2018
| Implemented |
| 6400.112(d) | The letter from the fire department states this residence has an extended evacuation time of 6 minutes during winter months. On 4/26/17 at 11:04pm, the evacuation was 5 minutes and 53 seconds. On 10/16/17 at 12:30am, the evacuation time was 5 minutes and 50 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | A fire expert has been contacted to review the evacuation procedures and time for approved evacuation time for the individuals who reside at this facility. Program Specialists and Management have been informed to closely review the approved evacuation time for each facility and to be more diligent with approved times and actual time reported during a drill. |
04/06/2018
| Implemented |
| 6400.114(b) | According to Prospectus' Smoking Policy, Employees and program participants may only smoke in the designated area. Smokers and users of tobacco products must dispose of its remains in the proper containers.' At this residence, there were approximately 15-20 cigarette butts in the left side of the yard (covered patio area) and also in the mulch in this area. | Written smoking safety procedures shall be followed. | Residential Services Administrator will review Prospectus Berco Smoking Policy with all management employees and expected that managers will review the policy with Direct Support Personnel. |
03/27/2018
| Implemented |
| 6400.151(c)(2) | Staff #1 was hired on 11/6/2017. She didn't have a TB test completed until 11/28/2017. | 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. | Applicants for hire will not be permitted to start work until Mantoux testing and reading is completed. |
03/09/2018
| Implemented |