| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Kitchen storage area had a spray bottle containing a mixture of bleach and water. | (c) Poisonous materials shall be stored in their original, labeled containers.
| The very same day as the inspection the bottle was removed from the home. In an all residential staff meeting held 11/28/2012 - policy was reviewed with staff regarding the labeling and storage of poisonous materials. Company has a policy regarding "Safety and Workplace Security" which outlines the use of a "Safety Audit" at minimum on an annual basis. It has been decided to increase these audits to be conducted quarterly. The policy in it's entirity was reviewed at the same residentail staff meeting on 11/28/2012. |
12/12/2012
| Implemented |
| 6400.72(b) | Kitchen area window screen is bent and not secured in the window frame. | (b) Screens, windows and doors shall be in good repair.
| The screen that had been bent was taken to the DuBois Glass Shop for repair on November 29, 2012. It is expected to be completed and placed back into the kitchen window by 12/14/2012. |
12/12/2012
| Implemented |
| 6400.81(k)(6) | There is no mirror located in Individual #2's bedroom. There is no documentation to indicate that Individual #2 does not wish to have a mirror in his/her bedroom. | (6) A mirror.
| A mirror was purchased for Individual #2's room on November 29, 2012. The mirror is awaiting installation pending Individual #2's ISP review scheduled for 12/5/2012 as the individual continues to state that he does not want a mirror in his room. |
12/12/2012
| Implemented |
| 6400.110(f) | The fire alarm system within the home is not equipped with devices to alert the individual in the event of a fire. Individual #2's physical examination, dated 3/7/12, indicates he has hearing loss. | (f) If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire.
| Smoke detectors with strobe feature were secured and installed in the home on 11/30/2012. |
12/12/2012
| Implemented |
| 6400.112(d) | Individual #1 did not evacuate the home in under 2 1/2 minutes during the fire drill held on 3/20/12. Individual #1 refused to participate in the drill. | (d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.
| Discussion with the client regarding the requirement to participate and to comply with walking to the designated site occured right after his refusal. There were no furher refusals after that one drill. Ongoing safety training and reminders at each and every drill continue to provide this consumer with education regarding the need for compliance. This was re-reviewed with Individual#1 following the licensing visit on November 28, 2012 with a note placed in his progress note for that date. |
12/12/2012
| Implemented |
| 6400.112(e) | A sleeping hours fire drill was not completed every 6 months. Sleeping hour drill was completed on 12/29/11 and not again until 11/10/12. | (e) A fire drill shall be held during sleeping hours at least every 6 months.
| Fire drills have been conducted monthly on a flexible schedule. It was decided to assure that drills were conducted at various times and to include during sleeping hours every 6 months that a schedule of drills would be set up each calendar year and followed to assure compliance. Grace Marshall and Vanessa Rowles will complete the schedule with Vanessa Rowles, Residentail Supervisor assuring it's compliance. |
12/12/2012
| Implemented |
| 6400.112(h) | Individual #1 did not evacuate to the designated meeting place during fire drills held on 4/24/12 and 5/31/12. Individual refused to evacuate to the designated meeting place. | (h) Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Individual #1 has complied with fire drills since that time period and is able to understand the importance of practicing them to completion. Fire safety was re-reviewed with him following the licensing visit and reflected via a progress note on November 28, 2012 to assure his compliance with all further drills. |
12/12/2012
| Implemented |
| 6400.141(c)(4) | A vision screening was not completed for Individual #1 on an annual basis. The two most recent vision screenings were completed on 4/11/11 and 5/4/12. | (4) Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
| Vision screenings have been recommended for this individual on an every two-year basis. His initial evaluation was scheduled as soon as it was feasible with the doctor's schedule as he was new to our area and was placed on a wait list. We have asked the doctor to include in his report a statement indicating that vision examination is required every two years. LPN, Leslie Stahl will assure that this information is included in doctor's orders. |
12/12/2012
| Implemented |
| 6400.163(c) | This is a repeat non-compliance (RNC). Three-month medication review for Individual #1, dated 3/14/12, does not include the reason for prescribing the medications. Medication review for Individual #1, dated 5/24/12, does not address the need to continue the medications. Medication reviews for Individual #1 did not occur at least every 3 months (a review was conducted on 5/24/12 and not again until 8/29/12). | (c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
| The doctor did not fill out the lower portion of our form which includes this information as there was no change from the last visit. Our LPN has advised the physician that all sections must be completed on each visit regardless if there is no change in medication or not. The original appointment with the doctor was scheduled for 8/24/2012 - which would have been in compliance with "every three months", however, it was rescheduled by the doctor for a week later. The LPN has secured a letter stating this to validate the delay. Grace Marshall, Director met with our LPN, Leslie Stahl on November 30, 2012 to review the requirements of paperwork and any delays/changes that occur in scheduling. |
12/12/2012
| Implemented |
| 6400.181(d) | The program specialist (Staff #1) did not sign Individual #1's assessment, dated 2/5/12. | (d) The program specialist shall sign and date the assessment.
| This was an oversight on the part of the Program Specialist. Her typed name was on the document. The Program Specialist will assure signature as required on all documentation. |
12/12/2012
| Implemented |
| 6400.181(f) | There is no documentation to indicate that Individual #'1 assessment was provided to plan team members within 30 calendar days prior to the ISP meeting held on 11/16/12. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The quarterly reports have been generally handed to the SC at the meeting or faxed over after. The Program Specialist attends the meeting. We are revamping this policy to require that the Program Specialist e-mail all copies of the quarterly evaluations to the SC and print a copy of the e-mail with time stamp as validation of receipt of the report. This e-mail will be maintained in the consumer record. Grace Marshall will assure compliance with this requirement. |
12/12/2012
| Implemented |
| 6400.186(b) | Individual #1 did not sign the ISP reviews dated 5/1/12 and 8/1/12. | (b) The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.
| Currently the ISP review sheets are maintained by the SC. Copies have neither been offered or given. The Program Specialist will assure that signature sheets will be made available and copied for the provider record. The forms identified by the licensor are not ISP review forms but quarterly reports given to the SC. |
12/12/2012
| Implemented |
| 6400.186(d) | There is no documentation to indicate that the program specialist (Staff #1) sent copies of Individual #1's ISP review documentation, dated 5/1/12 and 8/1/12, to the plan team members within 30 calendar days after the ISP review meetings. | (d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.
| Quarterly reviews are hand delivered while in attendance at the meetings and reviewed while at that meeting. We have adjusted our policy to assure that quarterly reports are sent ahead of the meeting via e-mail. With the e-mail as validation of the receipt of information. |
12/12/2012
| Implemented |