| 6400.31(b) | Individual #1's rights were late. They were signed on 07-15-16, then not again until 08-02-17. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Program Specialists and management have been informed that all Individual Right statements are to be reviewed and signed annually. This will be conducted at the ISP Annual Review Meeting. this will be reviewed at the March 27, 2018 Program Specialist/Management meeting |
03/27/2018
| Implemented |
| 6400.112(d) | The letter from the fire chief states In a worst case scenario, during winter months, a 3 minute evacuation would be acceptable'. There were four drills over 2 minutes and 30 seconds, none in winter months, seemingly due to insufficient staffing ratios:
04/14/17 -- Sleep drill at 12:50am. 2 minutes and 40 seconds, only 1 awake staff present to help these individuals, two of whom are in wheelchairs and one who is ambulatory with assistance.
07/31/17 -- Awake drill at 6:00pm. 2 minutes and 32 seconds, 2 staff present.
08/31/17 -- Awake drill at 3:30pm. 3 minutes, 2 staff present. The log stated physical assistance for Individual #1. and Individual #2s.' as the reason for the extended evacuation time.
10/31/17 -- Sleep drill at 12:30am. 3 minutes, only 1 awake staff present. | 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 |