| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | The right corner of the carpet on the back porch had a tear approximately 1½ ft. in length by 8 inches wide which could cause a tripping hazard. | (b) The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.
| The loose carpeting surrounding the tear was immediately cut back to eliminate a tripping hazard. The indoor/outdoor carpeting on the back porch will be evaluated. A correction will be made to replace / repair the missing section or to replace the entire piece of carpeting. The correction will be completed by 10/31/2013.
The Program Specialist and direct care employees will be trained on this regulation and expected to report any hazards. All training will be completed by 10/31/2013.
A monthly check of the home for hazards will occur when the fire drill is completed to ensure no hazards exist. The person implementing the fire drill is responsible for completing this check. A form has been developed to document this check and to check for other safety issues. This check will be used monthly for the next 6 months and then will be incorporated in a Quality Management Tool to ensure continued compliance. |
10/31/2013
| Implemented |
| 6400.101 | The basement door leading to the upstairs had a locking mechanism on the door which could cause an individual to become trapped in the basement. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The locking mechanism was immediately reversed to prevent someone from being locked in the basement area without a means of egress. The Program Specialist and the direct care employees will be trained on this regulation. All training will be completed by 10/31/2013.
The lock was on the door prior to our possession of the home. All other homes were checked for compliance. In the future, any new homes or anytime a lock is replaced in a current home, care will be taken to ensure there isn¿t a further violation. |
10/31/2013
| Implemented |
| 6400.186(e) | Individual #1¿s plan team members were not notified of the option to decline the 3-month Individual Support Plan reviews. | (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation.
| All agency Program Specialists were trained on this regulation on 9/25/2013. A form documenting the option to decline has been developed and used for all consumers across all facilities. The option to decline form will be sent to all team members and their preference will be noted. The completed form will remain on file in the chart for the person.
Option to Decline forms will be mailed out to team members by 9/30/2013. |
10/31/2013
| Implemented |
| 6400.195(d) | The restrictive procedure plans for Individual #1 dated 4/17/13 and 10/24/13 were not signed and dated by the Chairperson of the Restrictive Procedure Review Committee and the Program Specialist prior to the use of a restrictive procedure. | (d) The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| The signature sheet for this plan could not be located. A new signature sheet will be signed by the chairperson and the program specialist. A Human Rights Committee meeting is scheduled for 10/16/2013. The chairperson and the program specialist will review the plan and sign a new signature sheet for this plan. At this time, there are no other restrictive procedure plans used in the agency.
The Program Specialist will be trained on the regulation. All training will be completed by 10/31/2013.
In the future, all restrictive procedure plans will be signed and dated at the time of the meeting and a copy of the signature sheet will remain in a file at the administrative office. If the signature sheet in the house record is lost, there will always be another copy available. |
10/31/2013
| Implemented |