| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The front entry light was not operable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Who: 1. All staff in Residential Program
2. Maintenance department if repairs are needed.
3. The Director of Services (DOS), Assistant Director of
Services (ADOS) or ID Consultant to complete monthly
monitoring.
What: Ensure that all lighting is operable.
When: Ongoing for all staff in the Residential Program, as needed for the maintenance department when repairs are needed and monthly for the completion of the monthly Administration Regulation Monitoring Form. Lightbulb was replaced while BHS Licensing Representative was at the home.
How: 1. Retraining for all staff in the Residential Program
2. Maintenance will be notified of need for repair and will complete repair.
In the event that there is a concern where the maintenance department
does not complete the work or does not complete the work as per
regulations, the Executive Director will be notified by the DOS as per new
protocol.
3. Updated the Administrative Regulation Monitoring Form
Attachments:
¿ Signature sheet of all staff showing that they were retrained in regulations ( attachment # 3)
¿ Completed Administrative Regulation Monitoring form that was updated.(attachment # 5) |
09/19/2016
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not include staff and individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Who: Assistant Director of ID Services
What: Updated the form to include all regulatory requirements.
When: After form was found to be out of compliance with regulations.
How: Form was updated after licensing. All staff and individuals were trained in their responsibilities in the event that an evacuation must occur at one of the group homes. A copy of the form that was individualized for each individual, was placed in the individual¿s records at the home.
Attachments:
¿ Copy of the Emergency Relocation Plan for each individual (attachment # 1)
¿ Signature showing that all staff and all individuals were trained in their responsibility (attachment # 2 ) |
09/19/2016
| Implemented |
| 6400.104 | The fire notification letter sent to the fire department on 6/2/16 indicated that 2 individuals were independent with evacuation and one required verbal prompts. However according to the fire drill log from March 2015 until July 2016, the 2 "independent" individuals required verbal prompts to evacuate and the 3rd individual required physical prompts to evacuate. The notification letter was not kept current. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Who: Assistant Program Coordinator
What: Ensure that the letters to the fire department are accurate and current.
When: on going - as needed
How: An updated letter was developed to ensure consistency, as far as ensuring that all information is included in each letter. The APC who tracks the fire drill records will ensure that the type of assistance that is needed during a fire drill is the type of assistance that is documented on the letter to the fire department.
Attachments:
¿ Letter to fire departments that have been updated and mailed to each fire department (attachment #27).
¿ Letter signed by staff verifying that she has been trained in the POC (attachment #28)
) |
09/19/2016
| Implemented |