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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Most recent annual physical for staff member 6 occurred on June 2nd 2021, greater than 2 years ago. | 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. | Attachment 11
1. What was done immediately to correct the specific issue cited?
Program Director and Home Coordinator requested and retrieved a copy of his most recent physical dated 6/6/2023 and previous physical dated 6/2/21.
2. What specific change will be made?
Per the requirements for employee Annual Physical Exams, the annual physical requirements have been reinforced with the Home Coordinator regarding the annual timeframe. Upon submission, the agency recipient (Human Resources), is responsible to review the paperwork to ensure all required items are documented and in compliance with the identified timelines. Employees receive notification from the agency when their annual physical is coming due. On that notification, the employee's supervisor is also made aware to ensure prompt follow up through completion.
3. Who (by title) will make the change?
Home Coordinator is responsible for the full and prompt completion of their Annual Physical Exam on an annual basis. The responsible agency recipient (Human Resources), receives the employee annual physical exams, ensures all required information is present and meets the expectations set forth by the agency and ODP. Any discrepancies will be addressed immediately upon review and require immediate resolution.
4. When will the change be made?
This change has been made effective immediately as of 11/14/2023.
5. What system has been implemented to make sure the same violation does not occur again?
Home Coordinator and responsible agency recipient (Human Resources) work in collaboration with one another to ensure all annual physical requirements are completed entirely and submitted within the specified timeframe.
6. What education and training has been provided to staff?
Program Director educated Home Coordinator on 6400.151b on 11/20/23. |
11/14/2023
| Implemented |
| 6400.151(a) | No Physical Exam present in the file of staff 7 | 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. | Attachment 11.1
1. What was done immediately to correct the specific issue cited?
Program Director contacted Human Resources to request a copy of the employee's annual physical. Documentation was received to support the annual physical had been completed on 10/26/2022.
2. What specific change will be made?
Per the requirements for employee Annual Physical Exams, the annual physical requirements have been reinforced with the Home Coordinator regarding the annual timeframe. Upon submission, the agency recipient (Human Resources), is responsible to review the paperwork to ensure all required items are documented and in compliance with the identified timelines. Employees receive notification from the agency when their annual physical is coming due. On that notification, the employee's supervisor is also made aware to ensure prompt follow up through completion.
3. Who (by title) will make the change?
Home Coordinator is responsible for the full and prompt completion of their Annual Physical Exam on an annual basis. The responsible agency recipient (Human Resources), receives the employee annual physical exams, ensures all required information is present, and meets the expectations set forth by the agency and ODP. Any discrepancies will be addressed immediately upon review and require immediate resolution.
4. When will the change be made?
This change has been made effective immediately as of 11/14/2023.
5. What system has been implemented to make sure the same violation does not occur again?
The Home Coordinator and responsible agency recipient (Human Resources) work in collaboration with one another to ensure all annual physical requirements are completed entirely and submitted within the specified timeframe.
6. What education and training has been provided to staff?
Program Director educated Home Coordinator on 6400.151b on 11/20/23. |
11/14/2023
| Implemented |
| 6400.46(b) | Most recent documented fire safety training for staff member 7 occurred on November 7, 2022 | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Attachment 11.2
1. What was done immediately to correct the specific issue cited?
Immediately following the discovery of this citation, Program Director and HR confirmed employee in question was on leave of absence from work. This employee had not completed fire safety training due to this leave of absence. However, upon her return back to work she is required to attend fire safety training.
2. What specific change will be made?
Human Resources and Program Management are responsible for ensuring that documentation supporting an employee's leave of absence, as well as registration for training upon return, is provided at the time of inspection to support the area of non-compliance in question. A training tracker is also in development by the training department to assist managers with tracking of mandated training.
3. Who (by title) will make the change?
The Training Department distributes the training tracker; all supervisors and Program Managers are responsible for independently monitoring their employees training status to ensure follow up and completion in a timely manner. The training tracker is a topic discussed during monthly supervision.
4. When will the change be made?
November 2023
5. What system has been implemented to make sure the same violation does not occur again?
During monthly supervision, employees receive and review the training tracker along with their supervisor to ensure the employee's training compliance. Employee and supervisor are responsible to register for training, if necessary or provide verification of training completion.
6. What education and training has been provided to staff?
In new hire orientation, requirements regarding annual training are addressed by the Education Department. Also, during team meetings and monthly supervision the agency training requirements are reviewed for any coming due training to ensure compliance. |
11/14/2023
| Implemented |
| 6400.46(d) | There was no CPR certification on file for staff member 7. | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Attachment 11.3
1. What was done immediately to correct the specific issue cited?
Immediately following the discovery of this citation, Program Director and HR confirmed employee in question was on leave of absence from work. This employee had not completed CPR training due to this leave of absence. However, upon her return she is scheduled to complete the CPR/FA course on 3/27/24.
2. What specific change will be made?
Human Resources and Program Management are responsible for ensuring that documentation supporting an employee's leave of absence, as well as registration for training upon return, is provided at the time of inspection to support the area of non-compliance in question. A training tracker is also in development by the training department to assist managers with tracking of mandated training.
3. Who (by title) will make the change?
The Training Department distributes the training tracker; all supervisors and Program Managers are responsible for independently monitoring their employees training status to ensure follow up and completion in a timely manner. The training tracker is a topic discussed during monthly supervision.
4. When will the change be made?
November 2023
5. What system has been implemented to make sure the same violation does not occur again? During monthly supervision, employees receive and review the training tracker along with their supervisor to ensure the employee's training compliance. Employee and supervisor are responsible to register for training, if necessary or provide verification of training completion.
6. What education and training has been provided to staff?
In new hire orientation, requirements regarding annual training are addressed by the Education Department. Also, during team meetings and monthly supervision the agency training requirements are reviewed for any coming due training to ensure compliance. |
11/14/2023
| Implemented |
| 6400.52(a)(1) | Staff 6 had 21.25 hours of training logged for the 2022 training year.
** The email they sent had inaccurate math. Per the training summary he had the following:
3.75 hours in 2021
21.25 hours in 2022
41.5 hours in 2023 | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Attachment 11.4
1. What was done immediately to correct the specific issue cited?
Employee records were obtained on 11/14/2023, indicating that 24.55 hours of training were completed; training documentation was not provided in full at the time of inspection.
2. What specific change will be made?
Employees are responsible for utilizing the Individual Training Plan tool and review with their supervisor to track and update training needs throughout the year. The individual training plan is a self-directed tool that employees use to track their training compliance. The Individual Training Plan is reviewed during individual supervision. The Learning & Development Manager is responsible for showing employees how to use the individual training plan as well as the agency employee self-service portal, which tracks training compliance as well. The Employee Self-Service Portal is used independently by staff to track their training hours with the agency training department. The Individual Training Plan is reviewed with a supervisor to ensure employees are on track to complete 24 hours of training by the end of the training year. The Learning & Development Manager tracks trainings and provides monthly and annual updates and reminders to the program. Supervisors also receive monthly training reports. The training platform utilized, Relias, provides automatic reminders to employees when training is coming due or outstanding. Supervisors also receive automatic reminders to ensure training is complete. A ¿No Show¿ report is sent monthly by the Learning & Development Manager so Program Directors, Regional Directors, and Site Supervisors know when employees register for training but do not attend.
3. Who (by title) will make the change?
Employees, Supervisor, Program Director, Learning & Development Manager, and OED review training reports for employee compliance. The Program Director is responsible for following up with site supervisors on employee progress and status.
4. When will the change be made?
The changes were at the end of the 2023 training year.
5. What system has been implemented to make sure the same violation does not occur again?
Employees can track their own training hours using the individual training plan and the employee self-service portal. Additionally, they are sent reminders from Relias, their supervisors, and Learning & Development Manager.
6. What education and training has been provided to staff?
Employees are trained in how to use the Employee Self-Service Portal and Individual Training Plan. Employees and Supervisors are responsible for reviewing the Staff Development and Training Policy 3.3.4. |
11/14/2023
| Implemented |
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