| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.34(b)(2) | The home's civil rights policy does not include mention of physical accessibility and accomodation for individuals. | (2) Physical accessibility and accommodations for individuals with physical disabilities.
| The Civil Rights/Nondiscrimiation Policy was updated in June 2011. However, for the preinspection, the old policy was sent by mistake. All staff were informed of the new policy and copies made available. All policy manuals were reviewed to ensure the updated policy which includes language related to physcial accessiblity are in place. |
12/07/2012
| Implemented |
| 6400.46(g) | Staff # 1 did not have on record annual fire safety training. | (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).
| Staff #1 received Fire Safety Training on 12/11/12.JEVS implemented an annual training plan to ensure all required training occurs in an assigned month. All training is tracked in a tickler system for training compliance. |
12/11/2012
| Implemented |
| 6400.46(i) | Staff # 1 did not have current CPR training on record. | (i) 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.
| Staff #1 received CPR Training on 12/13/12. JEVS implemented an annual training plan to ensure all required training occurs in an assigned month. All training is tracked in a tickler system for training compliance. |
12/13/2012
| Implemented |
| 6400.103 | The homes' emergency evacuation procedures does not clearly define individual and staff responsibilities nor does it address the method of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The emergency evacuation procedure includes individual and staff respnsibilities with the method of transportation and the emergency shelter location. |
12/05/2012
| Implemented |
| 6400.151(c)(2) | Staff # 1 did not have on record updated TB testing. | (2) 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.
| Staff #1 completed TB testing on 12/5/12. A physical, including the TB test, tickler system has been implemented. The Administrative Secretary will monitor and send alerts to staff and director when the staff member is due for a physical to ensure compliance. |
12/05/2012
| Implemented |