| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(c)(2) | Staff 6 is 7 months overdue for TB screening. The most recent TB screening read negative 05/13/21, therefore, TB screening was due again on 5/13/23. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff had physical completed on 8/17/22, at which time TB was placed and read negative on 8/19/22. Staff again had an annual physical completed on 8/16/23, at which time she had a TB placed and read negative on 8/18/23. TB was placed once again on 8/30/23 and read negative on 9/1/23. |
02/26/2024
| Implemented |
| 6400.46(b) | Staff 6 attended Fire Training on 1/12/23, but no annual fire training was on file for the year prior. The most recent Fire Training on file prior to that date was 9/21/20. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff completed Certified Fire Safety Training on 2/17/22. Staff completed training again on 1/12/2023. Staff recently completed training for 2024 on 1/11/2024 |
01/11/2024
| Implemented |
| 6400.46(d) | The most recent CPR and First Aid Training attendance on file is dated 4/16/21. However, must attend annual emergency training for staff 6 | 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. | Staff completed CPR Training on 7/1/2022 and again on 6/15/23. Will renew CPR certification in June 2024. |
02/26/2024
| Implemented |
| 6400.52(c)(1) | Annual Trainings in record binder for 2021, but no Annual Trainings were in the binder the most recent training year of 2022 for staff 6 | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff completed 51 hours of training for training year 2024, all certificates included. 2023 annual trainings reviewed. |
02/26/2024
| Implemented |
| 6400.165(b) | Individual 2 i did not have his PRN MiraLAX available at site. (Only his daily was at site) | A prescription order shall be kept current. | Individual's PRN order of Miralax was discontinued as of 1/1/2024. February MAR included which shows no PRN Miralax order. |
01/01/2024
| Implemented |
| 6400.169(a) | The most recent Annual Practicum on file is dated 6/25/23, but no Annual Practicum is on file for 2022. The most recent Annual Practicum prior to 6/25/23 is dated 5/15/2020 for staff 6 | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Medication Trainer completed an updated Medication review, observation, and practicum for Individual #6 on 1/10/24. |
01/10/2024
| Implemented |