| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The 8 concrete steps leading out of the basement to the outside of the home do not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | A new handrail was install on 8/6/2020. The agency¿s safety committee will be completing quarterly inspections of each home to ensure compliance with regulation and safety concerns. |
08/06/2020
| Implemented |
| 6400.112(d) | Fire drill conducted 6/30/20 went over 2 minutes and 30 seconds. The fire drill was held at 7:30pm with both individuals residing at the home present. The fire drill was timed at 2 minutes and 50 seconds. There is no extended evacuation time at this home. | 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 employe 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. | Assigned House Managers are responsible for ensure monthly fire drills are accurately completed each month and that a sleeping fire drill is completed at least every 6 months. Each house manager has been retrained on this regulation including what is classified as sleeping hours. The house managers have also been retrained on the length of time individuals should safely evacuate the residence
Each house manager will turn in their fire drill sheets within 3 days of completion, each month, for the Program Specialist and/or the Residential Director to review for accuracy. All drills are completed by the 15th of each month in order to allow time for retraining as needed and to complete a new fire drill for accuracy.
The agency's Certified Safety Committee with also review all documentation of fire drills during their quarterly inspection of each home. |
08/11/2020
| Implemented |
| 6400.141(c)(1) | Individual #1's physical exam that was completed on 6/19/20 did not contain the medical history. This section was left blank on the physical form. | The physical examination shall include: A review of previous medical history. | House managers have been retrained on the documentation of annual physical exams. The agency has corrected the individuals exam that was cited.
To avoid further concerns, the Program Specialist will pre-populate all exam information required outside of the actual physical exam, leaving space for the attending physician to add information. The agency will also complete pre-population of the physicals in conjunction with the annual ISP meetings and the day prior to the exam. The assigned Program Specialist and/or the Residential Director will review all physical exams within 48 hours of completion to ensure compliance. If an exam is not documented properly, the house manager will return to the doctor¿s office to have the documentation completed within 2 business days. |
08/11/2020
| Implemented |
| 6400.141(c)(12) | The 6/19/20 annual physical exam completed for Individual #1 had a checked box NO. Individual #1 is a fall risk and a choking risk. Individual #1 also has a motion detector in the bedroom to alert staff when getting out of bed. These are not listed on the annual physical. | The physical examination shall include: Physical limitations of the individual. | House managers have been retrained on the documentation of annual physical exams. The agency has corrected the individuals exam that was cited.
To avoid further concerns, the Program Specialist will pre-populate all exam information required outside of the actual physical exam, leaving space for the attending physician to add information. The agency will also complete pre-population of the physicals in conjunction with the annual ISP meetings and the day prior to the exam. The assigned Program Specialist and/or the Residential Director will review all physical exams within 48 hours of completion to ensure compliance. If an exam is not documented properly, the house manager will return to the doctor¿s office to have the documentation completed within 2 business days. |
08/11/2020
| Implemented |
| 6400.141(c)(14) | This section on the 6/19/20 annual physical for Individual #1 was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | House managers have been retrained on the documentation of annual physical exams. The agency has corrected the individuals exam that was cited.
To avoid further concerns, the Program Specialist will pre-populate all exam information required outside of the actual physical exam, leaving space for the attending physician to add information. The agency will also complete pre-population of the physicals in conjunction with the annual ISP meetings and the day prior to the exam. The assigned Program Specialist and/or the Residential Director will review all physical exams within 48 hours of completion to ensure compliance. If an exam is not documented properly, the house manager will return to the doctor¿s office to have the documentation completed within 2 business days. |
08/11/2020
| Implemented |