Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.45(d) | Individual #1's 1:1 staff on 11/8/18 at the 3pm-7pm shift was not present in the home through review of time sheets. | The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). | The house manager, who completes scheduling, will ensure that all ratios are kept. He will alert CEO immediately for a back up. He will record anyitme ratio is not in compliance with resident's isp. |
01/18/2019
| Implemented |
6400.62(a) | The bathroom had unlocked cleaning products. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisons were locked during the inspection. The house manager will ensure that all cleaning products and poisons will be locked in the closet in the basement. |
01/18/2019
| Implemented |
6400.64(f) | The trash can in the back yard does not have a lid. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | A new trash can was purchased with a lid. The lids that tend to blow off, have been bungy-corded to the can to prevent this. |
01/25/2019
| Implemented |
6400.66 | The light fixture at the back door did not have a bulb. The basement exit did not have a light. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 6400.66
The light bulbs have been replaced by the landlord. The house manager will be responsible for checking for future stains. (photo has been emailed) |
01/18/2019
| Implemented |
6400.67(a) | The ceiling located in the basement had water stains. | Floors, walls, ceilings and other surfaces shall be in good repair. | 6400.67
The ceiling tiles have been replaced by the landlord. The house manager will be responsible for checking for future stains. (photo has been emailed) |
01/18/2019
| Implemented |
6400.70 | The telephone in the basement was inaccessible for the individuals living in the home. | A home shall have an operable, non coin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | A contractor has moved the landline up to the kitchen for greater accessibility. A photo will be sent via email upon completion.0 |
02/05/2019
| Implemented |
6400.81(k)(1) | In individual #2's bedroom, the mattress was on the floor. | In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. | A platform bed frame will be purchased so that resident cannot move it, thus causing possible injury to himself. The CEO will approve and purchase this. |
02/18/2019
| Implemented |
6400.111(f) | The fire extinguisher in the kitchen does not have an inspection tag. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 6400.111
The fire extinguisher was taken to General Fire Company to be recharged. ( A photo was emailed). The house manager will check these yearly. |
01/18/2019
| Implemented |
6400.112(d) | Individual #1 refused to evacuate during fire drills on 10/20/18 and 8/14/18. | 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. | The house manager will ensure that each core member eggresses under 2..5 minutes for the monthly fire drill.
The CEO will check on the monthly fire drills. |
01/18/2019
| Implemented |
6400.112(h) | The fire drill records did not have documentation of the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | 6t400.112
A new form was created that shows a meeting place area for sign in. (photo was emailed) |
01/18/2019
| Implemented |
6400.141(c)(10) | Individual #2's annual Physical Exam dated 6/27/2018 does not indicate if they are free of Communicable Diseases | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Upon admission into the program or homes, The Program Specialist will review the participants' physicals to ensure that the Free of Communicable Disease" section is checked off. If not, then remediation will be utilized, such as not accepting the individual into the program. |
01/18/2019
| Implemented |
6400.181(d) | Individual #2's annual assessment Date 1/11/18 the program specialist signed, but did not date the assessment. | The program specialist shall sign and date the assessment. | 6400.216
The Program Specialist will be advised by the CEO to sign and date assessments that she writes. CEO will read the assessments after the Program Specialist writes them. |
01/19/2019
| Implemented |
6400.181(e)(9) | Individual #2's annual assessment Date 1/11/18 did not document individual's disability. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | 6400.216
The Program Specialist will thoroughly understand her job description per the 6400 regulations, including writing a correct assessment which includes all necessary information such as individual's disability, functional and medical limitations. The CEO will read the assessments for required information. |
02/18/2019
| Implemented |
6400.181(e)(10) | Individual #2's annual assessment Dated 1/11/18 did not include a Lifetime Medical History. | The assessment must include the following information: A lifetime medical history. | 6400.181
Program Specialist will complete a Lifetime Medical History each anniversary year based on the 6400 regulations. The CEO will read over this report upon completion for accuracy and compliance. |
02/18/2019
| Implemented |
6400.181(f) | Individual #2's annual assessment Dated 1/11/18 was not sent to the supports coordinator. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Program Specialist will be trained on all areas of her job description as written in the 6400 regulations, including the correct procedure of sending the assessment to the Supports Coordinator. The CEO will check that the assessments are being sent to the Supports Coordinator both initially and annually. |
02/18/2019
| Implemented |
6400.216(a) | Individuals' files in the basement were left unlocked. | An individual's records shall be kept locked when unattended.
| 6400.216
The door knob on basement door was changed to a key lock door knob. The house manager will make sure it remains locked when the basement is not in use. The CEO will oversee the house manager. |
01/18/2019
| Implemented |