Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.84 | The facility did not have an annual onsite fire safety inspection by a fire safety expert. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | The facility made several attempts to local fire Departments throughout the year but were unsuccessful. After initial discussion with inspector, the facility contacted Code Officer Jeff Richardson who is a Fire Code Enforcement Inspector. He also inspected the building with new renovations completed on 4.29.21. Jeff is scheduled in the process of finishing the fire inspection form and will return it to PHS upon completion. [Fire safety inspection completed 5/26/21. Verified 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. |
06/30/2021
| Implemented |
2380.111(c)(10) | Individual #1's physical examination, dated 04/07/21, did not include medical information pertinent to diagnosis and treatment in case of emergency. This section of the physical examination was left blank. Individual #3's physical examination, dated 03/02/20, did not include medical information pertinent to diagnosis and treatment in case of emergency. This section of the physical examination was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program specialist will review all ATF individuals physicals and ensure all are up to date with all areas being filled out. If the PS finds that an area was not filled out they will reach out to the physician for clarification and documentation will be kept. [Individual #1's complete physical examination verified on 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. |
05/30/2021
| Implemented |
2380.113(a) | Direct Service Worker #1, date of hire 01/13/20, did not have an initial physical examination completed until 10/19/20. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | PHS administrator will schedule a pre-employment physical and Mantoux prior to DSP hire date when planned to work in a licensed setting. [3 staff physical examination were reviewed and verified to contain all required information on 7/15/21. DPOC by HDKP, HSLS, on 7/16/21]. |
05/30/2021
| Implemented |
2380.21(u) | Individual #1 was informed and explained individual rights on 01/07/21. Individual #2 was informed and explained individual rights on 06/23/20. Individual #3 was informed and explained individual rights on 07/21/20. Individual #4 was informed and explained individual rights on 06/22/20. The rights document did not include the following rights: 2800.21(b) The facility shall educate, assist and provide the accommodation necessary for the individual to understand the individual's rights; 2800.21(c) An individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; 2800.21(d) A court's written order that restricts an individual's rights shall be followed; 2800.21(e) A court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2800.21(f) An individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2800.21(g) An individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2800.21(h) An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age; 2800.21(k) An individual shall be treated with dignity and respect; 2800.21(l) An individual has the right to make choices and accept risks; 2800.21(m) An individual has the right to refuse to participate in activities and services; 2800.21(n) An individual has the right to privacy of person and possessions; 2800.21(o) An individual has the right of access to and security of the individual's possessions; 2800.21(p) An individual has the right to voice concerns about the services the individual receives; 2800.2 (q) An individual has the right to participate in the development and implementation of the individual plan | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | Individuals Rights Form was updated immediately upon discussion of the violation on 5.13.21. [Updated Individual Right form verified 7/15/21. Updated forms signed by individuals by 5/19/21. DPOC by HDKP, HSLS, on 7/16/21]. |
07/01/2021
| Implemented |