| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.56 | The men/women bathrooms did not have working ventilation, no windows were present the fans were not operational. | Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning. | During all previous inspections, the lack of bathroom fans was raised and in all previous years the building was exempted due to the age of the building and the location of the bathrooms not having a bath to vent due to their being underground. The landlord has agreed to install ductless bathroom fans by 1/31/2024. |
01/31/2024
| Implemented |
| 2380.91(a) | Fire safety for individual #2, was not completed. Individuals are to receive fire safety training in their own language. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | As presented on day of inspection, individual #2 had the fire safety training using picture icons and use of sign language by Deaf staff. However, the reviewer did not accept the level of documentation that we had provided as sufficient to assure this regulation was in complaince. We have adapted our fire safety training form for all individuals to include a section that indicates the individual's preferred language and mode of communication from the ISP and the language/method that was used to deliver the training. A new training was conducted for Individual #2 with an interpreter present on 11/01/2023. The new signed and completed form is available in Appendix A. A review of all other 5 individuals was conducted and none were found to have received the training in a language other than English, their preferred language. |
11/01/2023
| Implemented |
| 2380.129(a) | Staff #2 did not successfully complete the medication administration renewal course requirements; staff may not administer medications to individuals until training is completed and proof is provided. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | While medication renewals were being conducted regularly by our nurse who is our Certified Medication Administration trainer, she did not completely understand how the documentation of the required annual renewal was to be completed and was doing so incorrectly. The staff person #2 was preented from administering medications until it was determined that all applicable observations had in fact occurred at the required times. The correct paperwork was completed demonstrating that annual observations had been completed in accordance with regulations. After reviewing all staff records, 3 additional staff were found to have incorrectly documented annual reviews. The nurse was retrained and all corrections were completed. Corrected form for Staff #2 is included in Appendix B. |
09/29/2023
| Implemented |
| 2380.129(d) | The training record for Staff #1 was not dated as required on his Annual Practicum. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | While medication renewals were being conducted regularly by our nurse who is our Certified Medication Administration trainer, she did not completely understand how the documentation of the required annual renewal was to be completed. The staff person #1 form was corrected by the nurse/ Certified Medication Adminsitration Trainer.. The correct paperwork was completed demonstrating that annual observations had been completed in accordance with regulations. The first 6th month review for the next annual practicum cycle was due and was completed on 09/27/2023. After reviewing all staff records, 3 additional staff were found to have incorrectly documented annual reviews. The nurse was retrained and all corrections were completed. Corrected form for Staff #1 is included in Appendix C. |
09/29/2023
| Implemented |
| 2380.181(f) | There is no date on the ISP invitation letter for individual #1. Letters are to be sent 30 days prior to SC. Cannot determine what date the letter had been sent as there was no proof of date letter was sent. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | When the ISP invitation letter for Individual #1 was sent, it was not recognized that the letter was missing a date. The SC was contacted and a revised letter with a date was provided. The Program Specialist has been retrained in needing to review all ISP letters to assure their completeness so that they can demonstrate . A calendar exists for the Program Specialist to routinely send out the Annual Assessment for each individual 90 days prior to the ISP Annual Update deadline, since nearly all ISP meetings occur between 60-90 days prior to that date. Evidence of these documents is included in Appendix E. |
10/27/2023
| Implemented |