Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.33(g) | The agency is utilizing video cameras to monitor and record in the hallways, living room, dining room and other common areas of the home. | An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. | The use of the cameras was discontinued and will not be utilized in the future. Residential staff are trained on Client Rights including the right to privacy at orientation and annually thereafter.
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01/30/2017
| Implemented |
6400.112(f) | The monthly fire drills completed between November 2015 and November 2016 used the front door to evacuate. The home has two means of egress. | Alternate exit routes shall be used during fire drills. | The staff members at the site were retrained on evacuation procedures on 1/7/17 and the document was submitted to BHSL on 1/10/17. All fire drill logs will be audited by 3/31/17 by the Asst. Res Director to ensure that alternate exits are being used. If a site is found not to be using alternate exits, the staff will be retrained on evacuation procedures immediately.[Within 30 days of receipt of the plan of correction, all staff persons responsible for conducting fire drills shall be trained in the requirements as per 6400.112(a)-(i).Immediately, CEO shall develop procedures for the Asst. IDD Directors to follow if upon review of fire drill records it is found fire drills are not being conducted as required and train the Asst IDD Directors on the procedures. Documentation of trainings, procedures and reviews shall be kept. (AS 2/3/17)] |
01/30/2017
| Implemented |
6400.168(c) | Documentation of Direct Service Worker #1's medication administration training, completed on 10/16/16, was not signed by a certified instructor. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | The Res. Program Specialist is scheduled to attend Med. Admin train the trainer by the summer of 2017 and will be completing medication practicums upon completion of the training. The Res. P.S. will be oriented to these duties when trained. The Asst. Res Directors will review medication administration training records to ensure that they are completed in their entirety within the week of completion.
[Direct Service Worker #1 will not administer medications until medication administration training is completed in its entirety. Immediately and prior to staff administering medications, the Asst. Res Directors will review all medication administration training records to ensure training is completed in its entity. Documentation of medication reviews shall be kept. (AS 2/3/17)] |
01/30/2017
| Implemented |