| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | Direct Service Worker #1, date of hire 2/15/18 did not have orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals. Direct Service Worker #3, date of hire 10/4/18 did not have orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Temp. records will be reviewed to ensure that all current temp employees have received required trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. |
12/31/2018
| Implemented |
| 6400.46(d) | Direct Service Worker #2, date of hire 7/13/16, did not have 24 hours of training for training year 1/1/17-12/31/17. | 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. | Temp. records will be reviewed to ensure that all current temp employees have received required trainings by 12/31/18. The Director of IDD Services will draft and send a letter to all temp. agencies by 12/31/18 stating the training requirements for all employees who work directly with individuals. Monthly, the Office Manager and Assistant Directors will compare the active temp. staff list with the temp. staff who are actively working at the site. All temp. staff who are working at the sites for 40 hours or more monthly will be included in the agency training curriculum to accrue 24 training hours. The Office Manager will maintain all training records for temp. staff. |
12/31/2018
| Implemented |
| 6400.46(f) | Direct Service Worker #1, date of hire 2/15/18 did not have training in general fire safety. Direct Service Worker #3, date of hire 10/4/18 did not have training in general fire safety. Direct Service Worker #2, date of hire 7/13/16 was most recently trained on general fire safety training on 7/13/16. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Temp. records will be reviewed to ensure that all current temp employees have received required annual trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. |
12/31/2018
| Implemented |
| 6400.46(i) | Program Specialist #1, date of hire 4/10/17, has not been trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The Program Specialist received CPR training on 12/11/18. The Program Specialists were added to the due date tracking spreadsheet that is currently used for DSPs. The spreadsheet will be reviewed at least monthly by the Program Specialists for due dates and quarterly by the Assistant Residential Directors. |
12/11/2018
| Implemented |
| 6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| An emergency phone number sticker was placed on the phone the following day by a DSP. All phones at all sites will be checked for the presence of the emergency stickers by 12/31/18 by the Site Supervisors. Quarterly, the phones will be checked by the Health and Safety Committee and stickers will be placed on any phones on-site. Documentation of on-site visits will be maintained by the Health and Safety Committee. |
12/31/2018
| Implemented |
| 6400.151(a) | Direct Service Worker #3, date of hire 10/4/18, did not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Temp. records will be reviewed to ensure that all current temp employees have a current physical in their record by 12/31/18. The Director of IDD Services will draft a letter by 12/31/18 to send to all temp. staff agencies that an employee physical is required prior to any of the temp staff being scheduled at any of the sites. The letter will also state that the physical needs to be sent via fax or email to the Office Manager to keep in an employee file. Quarterly, the Director of IDD Systems will review 10% of temp. staff files to ensure that the employee¿s physical is present for the next calendar year. |
12/31/2018
| Implemented |