| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The emergency evacuation procedure did not include the individual's responsibilities during an emergency evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| A new evacuation plan was developed and provided to the staff and individuals of the home. |
06/19/2019
| Implemented |
| 6400.104 | The fire department notification letter was not dated. It is unclear when the letter was sent to the fire department. | 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.
| A new letter was sent to the Upper Yoder Fire Department with the date of June 10, 2019. A template has been created to use to include the date the letter was sent. |
06/10/2019
| Implemented |
| 6400.143(a) | Individual #1 has not been to a gynecologist for the past ten years. The reason for this is due to her anxiety and does not want to attend these appointments. A doctor's order 3/13/2019 from CRNP Ralph Aiken from Windbercare Physicians is deferring individual #1 from these appointments and stating specifically, pap smears. She does not have a desensitization plan in place for her anxiety over gynecological appointments. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A desensitization plan has been constructed and implemented regarding her refusal to participate in these exams. The staff have been trained on the plan and the plan has been added to her daily log sheet to ensure proper tracking. |
06/18/2019
| Implemented |
| 6400.151(a) | Staff #3's date of hire was 2/18/19 and the physical was dated for 2/27/19. Staff #2 date of hire was 11/12/18 and the physical was dated for 11/19/18. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The agency has updated the Quality Management in Hiring Policy to include a list of items that must be completed prior to their start date, which includes the initial physical exam of staff. |
06/17/2019
| Implemented |
| 6400.151(c)(2) | Staff #3's date of hire was 2/18/19 and the tuberculin skin test was dated on 2/27/19. Staff #2's date of hire was 11/12/18 and the tuberculin skin test was dated 11/19/18. | 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. | The agency has updated the Quality Management in Hiring Policy to include a list of items that must be completed prior to their start date, which includes the Tuberculin skin test. The agency has also opted to move to the one-step test for efficiency. |
06/17/2019
| Implemented |
| Article X.1007 | OAPSA-criminal background check- Staff #3's date of hire was 2/18/19. Her criminal history background check wasn't completed until 2/20/19. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | The agency has updated the Quality Management in Hiring Policy to include a list of items that must be completed prior to their start date, which includes the criminal background check. |
06/17/2019
| Implemented |