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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean and sanitary conditions was not maintained in the house. | Clean and sanitary conditions shall be maintained in the home. | What was done immediately to correct the specific issue cited?
On 11/15/2022 the Site Supervisor was made responsible for the cleaning of the areas in question. On 11/15/2022 all areas throughout the home were cleaned properly and according to expectations.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change was implemented immediately on 11/15/2022.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #18.1 |
11/15/2022
| Implemented |
| 6400.72(b) | The screen door located in the kitchen is damaged and in need of repair. | Screens, windows and doors shall be in good repair. | What was done immediately to correct the specific issue cited?
Program Director discussed the matter with the maintenance Supervisor who was present at time of inspection on 11/15/22. On 1/9/2023 this matter was resolved.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change was implemented immediately on 11/28/2022
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #18.2 |
11/28/2022
| Implemented |
| 6400.72(b) | The window in Ind. #18 bedroom was damaged and in needs repaired or replaced. | Screens, windows and doors shall be in good repair. | What was done immediately to correct the specific issue cited?
Program Director submitted maintenance on 11/15/22 for the window to be repaired to ensure its operable. On 1/9/2023 the window was repaired.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change was implemented immediately on 11/28/2022.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #18.3 |
11/28/2022
| Implemented |
| 6400.112(e) | No sleep fire drill was conducted every six months as required. From 11/2021 -- 09/2022 no sleep drills done. | A fire drill shall be held during sleeping hours at least every 6 months. | What was done immediately to correct the specific issue cited?
An overnight fire drill was conducted on 11/21/22.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Monthly requirements such as: fire drills, record reviews, and training documentation. In order to ensure regulatory and agency expectations and compliance, all staff are trained and provided with a reference guide regarding submission dates. Site Supervisors are the first to review the fire drill, next the Program Director, and lastly the fire drill gets submitted to QI. Should the Site Supervisor or Program Director discover errors, the fire drill is immediately reviewed with the facilitator to address and resolve the error. Should QI discover errors, it is the Program Directors responsibility to address and resolve the error. Additionally, the Regional Director is responsible for addressing the importance of review with the Program Director. Monthly, QI will be tracking timely submissions and accuracy.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change went into effect on 11/21/22.
What system has been implemented to make sure the same violation does not occur again?
All staff are required to conduct at least one (1) overnight fire drill every six (6) months at the residence site. Once complete, Site Supervisors are responsible for the review and submission of the fire drill to Program Directors. Following the Program Director review, the monthly fire drills are submitted to QI. Site Supervisors and/or Program Directors are responsible for discovering any errors during the drill and addressing those errors with the facilitator. The facilitator is responsible for the resolution. If QI discovers the error, the Regional and Program Directors are informed and the Regional Director is responsible for addressing the matter with the Program Director. QI discovered errors will be resolved immediately. QI tracks the punctuality and accuracy of all fire drills to ensure all locations are in compliance.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022; A fire drill shall be held during sleeping hours at least every 6 months All staff are aware that any regulatory violation associated with fire drills requires immediate resolution. All staff and Site Supervisors have been trained on the expectations of conducting fire drills and the supporting documentation.
Attachment #18.4 |
11/21/2022
| Implemented |
| 6400.141(c)(4) | The physical exam form for Ind. #14 dated 12/22/2021 did not address vision and hearing screening for the individual. The vision form dated 08/19/2022 recommended that individual have a follow-up in 6 weeks, no follow-up was scheduled or conducted. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | What was done immediately to correct the specific issue cited?
6400.141c14 ¿ The physical examination shall medical information pertinent to diagnosis and treatment in case of emergency. Information on diagnosis in case of emergency was left blank on physical form 12/21/22.
On 11/16/22 Program Director pulled 2020 Annual Physical for FD. Program Director called PCP office regarding 2021 Annual Physical and was advised the 2021 Physical would be updated at upcoming appointment on 12/28/22.
What specific change will be made?
On 12/28/22 information will be filled in on the 2021 Annual Physical.
Who (by title) will make the change?
PCP office will make the change.
When will the change be made?
On 12/28/22 information will be completed on the 2021 form.
What system has been implemented to make sure the same violation does not occur again?
Supervisor will accompany individual on all Annual Physical appointments to ensure accuracy and full completion of required forms.
What education and training has been provided to staff?
Program Director educated all current staff on expectation regarding Annual Physical Form completion in the event that they need to accompany individual on appointment on 11/16/22. Supervisor will accompany individual on all Annual Physical appointments to ensure accuracy and full completion of required forms when possible. Program Director will review all Annual Physical Forms after appointments to ensure accuracy and to address concerns immediately.
Attachment #18.7 |
12/28/2022
| Implemented |
| 6400.141(c)(6) | On the annual physical form dated 12/22/21 the TB read date was left blank for Ind. #14. Test was completed on 12/22/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | What was done immediately to correct the specific issue cited?
The 2020 and 2021 annual physical exams were placed in the health record of the individual FD. Both document the date and negative reading of the ppd. Current annual physical exam dated 12/28/22 contains documentation for the placement and reading of the ppd on 12/30/22 also with a negative reading.
What specific change will be made?¿
Site Supervisor will utilize the yearly medical calendar to keep track of appointments. During the time of the annual appointments the Supervisor will schedule for the upcoming year. If that is not possible the supervisor will mark the calendar at the 6-month period to schedule the yearly appointment. Upon completion of medical appointments, the Supervisor will scan medical documentation to the assigned agency nurse for review to ensure all information is completed on the physical form.¿¿¿¿
¿
Who (by title) will make the change?¿
Site Supervisor (Program Director in absence of Supervisor) and Agency Nurse.¿
¿
When will the change be made?¿
The change was made effective November 16, 2022 when documents verifying tb test was completed in 2021 were placed in the health record of the individual.¿
¿
What system has been implemented to make sure the same violation does not occur again?¿
When all medical appointments are completed, the Site Supervisor will scan the documents to the assigned agency nurse. The nurse reviews the medical documentation for accuracy and completion. Program Directors also review medical documentation on a quarterly basis.¿
¿
What education and training has been provided to staff?¿
Program Director reviewed 6400 regulations specifically related to violations received during the 2022 inspection and the Individual Health record regulations for participant health 6400.141 ¿ 6400.141c.15 on 11/28/22.¿
Attachment # |
11/16/2022
| Implemented |
| 6400.181(a) | Ind. #14 did not have an assessment completed annually, previous assessment was completed on 05/05/21 and current was not completed until 07/25/22. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | What was done immediately to correct the specific issue cited?
ISP tracker was updated to add correct dates of the next assessment date of 7/21/23.
What specific change will be made?
An automated tracking system was developed that color codes when documents are due. Program Specialists will use this automated tracker as a tickler to complete assessments when they are due.
Who (by title) will make the change?
Program Specialist, Director of Service Coordination
When will the change be made?
The change was made 11/18/22.
What system has been implemented to make sure the same violation does not occur again?
An automated tracking system was implemented that alerts program specialists through color coding on when the annual assessments are due. The Dir. of Service Coordination will review the tracker at monthly and address accordingly with each Program Specialist to ensure the assessments are updated as needed.
What education and training has been provided to staff?
A review of dates for annual assessments was completed with the program specialist, as well as a review of the regulation for the assessment to be completed annually. Program Specialist will be trained during initial orientation on the use of the automated tracking system.
Attachment #18.9 |
11/18/2022
| Implemented |
| 6400.32(s)(2) | Neither the staff or individuals has access to the thermostat if needed, as there is a lock box present with no key to open and change temperature if the need arises. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | What was done immediately to correct the specific issue cited?
Program Director obtained a key to the thermostat and attached it to the thermostat cover on 11/15/22. There is access to the thermostat for all. Program Director requested that all thermostat covers be removed throughout the program. Maintenance Director confirmed this action will be taken care of. Matter was resolved on 12/30/22.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting the site inspection and completing the checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation will initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director corrected the issue on 11/15/22. Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Change was made same day as inspection 11/28/2022 and 12/30/2022.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/2022; the locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #18.5 |
11/28/2022
| Implemented |
| 6400.163(d) | The prescription medication for all individuals stored in the closet was not kept locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | What was done immediately to correct the specific issue cited?
On 11/15/2022, Program Director locked the closet holding the medication boxes. Keys to this locked closet are hung in a designated spot in the office and all staff are aware and have access to them.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting the site inspection and completing the checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation will initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change
When will the change be made?
Changes went into effect on 11/15/2022 when the medications were securely locked. The revised weekly residential site checklist and its process have been implemented in all residential locations to ensure thorough inspections are completed weekly.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/28/22 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. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #18 |
11/15/2022
| Implemented |
| 6400.181(f) | The program specialist did not provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. No verification was provided during inspection. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | What was done immediately to correct the specific issue cited?
The program specialists have developed a tracking system and incorporates all aspects of the ISP process, which includes time frames for sending the ISP meeting invitation to the team members prior to the ISP meeting.
What specific change will be made?
The Director of Service Coordination will discuss various aspects of the ISP process in supervision with program specialists to ensure that they are following up in a timely manner with the ISP meeting notification to team members. This information will also be tracked on the ISP tracking system.
Who (by title) will make the change?
Program Specialist, Director of Service Coordination
When will the change be made?
The change was made 11/14/2022
What system has been implemented to make sure the same violation does not occur again?
ISP Checklist is documented beginning at the 120-day timeframe before the Annual Review Update of the ISP is due. It will capture the due dates of various items that are due prior to the ISP due date, including providing the assessment to individual¿s team members 30 days before the ISP meeting.
What education and training has been provided to staff?
The expectations around ISP notification was reviewed with the Program Specialist on 11/14/2022. The ISP checklist will also be reviewed with new Program Specialists.
Attachment #18.10 |
11/14/2022
| Implemented |
| 6400.213(1)(i) | Individual's #14 record did not contain identifying marks, it was omitted on the face sheet. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | What was done immediately to correct the specific issue cited?
Face sheet for participant FD, was updated on 11/20/22, by documenting identifying marks. The corrected document was placed in FD¿s health record.
What specific change will be made?
Program Specialist and Program Managers review face sheets during quarterly reviews, ensuring all areas are completed using the identified checklist.
Who (by title) will make the change?
Program Specialist and Program Supervisor
When will the change be made?
11/20/22
What system has been implemented to make sure the same violation does not occur again?
Upon completion of the Face Sheet, Program Specialist or Program Supervisor will use the checklist that will ensure all areas of the participant¿s face sheet is filled in correctly. The chart review form has also been updated to ensure that it captures whether the Face Sheet has been completely filled out. Any incomplete areas on the Face Sheet will be immediately addressed by Program Specialist and Program Supervisor.
What education and training has been provided to staff?
Program Specialists were reminded of the need to ensure all personal information for participants is reviewed and updated on an annual basis, and that the form is completely filled out. The face sheet was reviewed with the program specialist outlining all the areas of the face sheet that must be completed.
Attachment #18.6 |
11/20/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water temperature was 130 degrees. The water temperature was corrected during inspection. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 1. What was done immediately to correct the specific issue cited?
Upon discovery of the high water temperature, the water heater was assessed and had to be replaced, on 11/16/2021.
2. What specific change will be made?
To ensure that the water temperature is checked monthly, the written water temperature will now be included on the monthly fire drill form. The House Manager will review each fire drill form and if the water temperature exceeds 120°F, the House Manager will immediately complete a work order to our Real Estate Department. A phone call will also be placed to the Real Estate Dept on-call emergency hotline to expedite the process. The Program Director will oversee the repairs to ensure that it is done immediately.
3. Who (by title) will make the change?
The Site Manager, Program Director, Regional Director
4. When will the change be made?
11/17/2021
5. What system has been implemented to make sure the same violation does not occur again?
The use of the Real Estate on-call emergency hotline system has been implemented at the site. This will be used by staff to report any emergent needs of the environmental setting. The on-call emergency system will generate a notification to alert the program management staff that the issue is being addressed. The program director will monitor and follow up within one hour to ensure that the issue is resolved, and continue to follow up if needed to ensure resolution.
6. What education and training has been provided to staff?
On 11/17/21 the program director educated the site supervisor on the allowable water temperature for the home and that it should never exceed 120 degrees to prevent accidental scalding.
Attachment #8 |
11/17/2021
| Implemented |
| 6400.112(c) | The fire drill dated 4/5/21, time of drill was missing, fire drill dated 8/31/21 the amount of time it took for evacuation was missing. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | What was done immediately to correct the specific issue cited?
On 11/17/2021, the Regional Director met with Program Director to review the 6400.112c regulations that includes the elements of the fire drill forms, such as the time of the drill and the evacuation time.
2. What specific change will be made?
The Regional Director reviewed the new Fire Drill Process and Annual Monthly Fire Drill Tracker with the Program Director. The Program Director will train the staff at the site by 12/31/21. The program director will conduct a thorough review of completed fire drills forms on a monthly basis to ensure that all drills are completed and the forms are completely filled out. Verification of this review will be captured on the Annual Monthly Fire Drill Tracker that will be reviewed monthly by the Regional Director during monthly supervisions with Program Directors.
3. Who (by title) will make the change?
The Site Supervisor, Program Director, Regional Director
4. When will the change be made?
December 31, 2021
5. What system has been implemented to make sure the same violation does not occur again?
The Site Supervisor will submit the completed fire drill form to the Program Director by the 3rd week of the month. The program director will conduct thorough reviews of completed fire drills forms on a monthly basis and provide immediate education and feedback to the Site Supervisor when it is discovered that information is missing from the forms. Verification of this review by the program director will be documented on the Annual Monthly Fire Drill Tracker each month. During the program director¿s monthly supervisions with their site supervisor, an additional review of drills will be conducted during the meeting as an added precaution.
6. What education and training has been provided to staff?
The Regional Director reviewed regulation 6400.112c with the Program Director and stressed the importance of their oversite responsibility in their reviews of the fire drill forms to prevent the reoccurrence of the this citation.
Attachment #8.2 |
12/31/2021
| Implemented |
| 6400.112(e) | This location did not have any sleep drills provided. The drill completed on 1/8/21 indicated the individuals were asleep but the time is listed as 1PM. | A fire drill shall be held during sleeping hours at least every 6 months. | What was done immediately to correct the specific issue cited?
On 11/17/2021, the Regional Director met with home leadership to review the 6400.112e regulations that requires community home providers to conduct an unannounced fire drill to be held at least once a month and an overnight drill every 6 months.
2. What specific change will be made?
The program director reviewed the new Fire Drill Process that incorporates completing an overnight drill at least every 6 months with the Site Supervisor. The Site Supervisor will train the staff at the site by 12/31/21. The process includes completing the unannounced overnight drill in a designated month for all programs, so that all locations will become accustomed to doing unannounced overnight drills in the same designated months. During the program director¿s monthly supervisions with their site supervisor, the Monthly Fire Drill Tracker will be reviewed to ensure that staff are completing the drills according to the Fire Drill Process.
3. Who (by title) will make the change?
The Site Supervisor, Program Director, Regional Director
4. When will the change be made?
December 31, 2021
5. What system has been implemented to make sure the same violation does not occur again?
To supplement the Emergency Response Policy and Procedure, a Fire Drill Process was developed that incorporates monthly reminders using a Monthly Fire Drill Tracker. The program director will train all relevant staff on the new Fire Drill Process by 12/31/21. To ensure that the site is compliant in conducting the required number of ¿overnight¿ drills per year, the ¿Annual Monthly Fire Drill Tracker¿ will be filed in the front of the Fire Drill Binder at the site. The Monthly Fire Drill Tracker indicates the designated months that the unannounced overnight drills will be completed. The tracker will be the first page of the binder and will be accessible to all staff working at the site, who will complete the tracker after the completion of each drill. At least quarterly, during monthly staff meetings, Site Supervisors will review the timeframes for unannounced overnight drills to ensure that staff are on target to complete them. The Site Supervisor, Program Director, and Regional Director will review the tracker specifically for the overnight drills at least quarterly.
6. What education and training has been provided to staff?
The Regional Director reviewed regulation 6400.112e with the Program Director and stressed the importance of their oversite responsibility in ensuring that unannounced overnight drills are completed at least every 6 months. Staff at the site will also be trained on the new Fire Drill Process by 12/31/21.
Attachment #8.1 |
12/31/2021
| Implemented |
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