| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff #1 fire last fire safety training was completed on 4/4/12 and the current fire safety training was completed on 4/17/13. | (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).
| Fire Safety training has been completed for staff person 4/17/13.
All staff will receive messages to schedule and attend required training.
The Staff Development Department will provide Program Directors with reports on the status of completion of training requirements for all staff.
Program Directors will use reports to monitor completion of required training and, as appropriate, implement corrective action for any staff person who fails to attend required training. |
08/31/2013
| Implemented |
| 6400.67(c)-1 | Individual #1 has a diagnosis of PICA and the home was not tested for lead paint. | (c) If the home serves an individual 4 years of age or younger or an individual who ingests paint or paint substances, the home shall test all layers of paint at the home for lead content.
| Facilities Department will provide to DPW written verification that paint in Carriage House is lead free. |
07/25/2013
| Implemented |
| 6400.112(f) | The front door was used for fire drills held 5/25/12, 6/16/12 and 7/14/12. | (f) Alternate exit routes shall be used during fire drills.
| Program Director will review requirements for drills with site supervisors and provide guidance, in the form of sample calendars with varied exits, to ensure alternate exits are used.
Drills will be monitored by Program Directors and Compliance to ensure requirements are met.
When conducting drills staff will refer to records of previous drills to prevent patterns and ensure that drills are held at various times of day, on various days of the week and use varying exit routes |
07/09/2013
| Implemented |
| 6400.141(c)(15) | Nutritional consult completed 1/13/12 for individual #1 recommended second helping at meal time was not included on annual physical completed 11/29/12. | (15) Special instructions for the individual's diet.
| Individual #1s physical will be updated to reflect special instructions for diet.
The Healthcare coordinator will provide diet instructions recommended by consults for review by physicians completing annual physicals so that this information can be included in reports of physicals. |
07/16/2013
| Implemented |
| 6400.163(c) | Individual #1 completed a 90 day medication review on 2/22/13 with recommendations for a follow up appointment to occur within a month. The follow up appointment was not completed until 5/10/13. | (c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
| The follow up appointment for individual #1 was held within 3 months in compliance with regulations. Melmark staff will schedule follow up appointments at the time of physician visits to ensure that appointments occur within recommended and required time frames. |
07/09/2013
| Implemented |
| 6400.181(d)(3) | The ISP for individual #1 dated 1/17/13 was not documented on the Departments designated HCSIS form. | (3) The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) and also on the Department's web site.
| Melmark will ensure that all elements of the DPW designated form are included in an electronic document so that all ISPs will be documented with DPW required content. |
08/09/2013
| Implemented |