| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The First Aid Kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A checklist will be created and Admin Assistant will check all kits monthly. Admin assistant will compile a list of missing items and forward to the facilities coordinator for ordering. |
04/01/2020
| Implemented |
| 6400.112(c) | The sleep fire drill dated 9/26/19 did not notate the amount of time the fire drill took place on the document provided. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All Jami employee's will participate in a refresher documentation writing training course to ensure that all forms are completed correctly and in its entirety. |
06/30/2020
| Implemented |
| 6400.113(a) | Initial fire safety training upon admission on 7/12/19 was not documented on individual 1's record, annual training was completed 3/8/2020 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home. | All consumers will complete a fire safety training when they first move in and sign a consent stating it was completed, accompanied with an initial fire drill |
04/01/2020
| Implemented |
| 6400.141(c)(3) | Current Immunizations were not documented in individual 1's record. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The program specialist will obtain all dates of the last scheduled immunization record, if they are out of date the consumer will be scheduled and all required documentation will be updated with the correct information)- ADD TO LTM- AND ASSESSMENT- (information was included in the life time medical not in the assessment) |
04/01/2020
| Implemented |
| 6400.181(c) | The assessment dated 8/12/19 for individual 1 did not notate what it was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The program specialist will identify and not all resources used to obtain information for all assessments |
04/01/2020
| Implemented |
| 6400.181(e)(7) | Knowledge of heat sources was not discussed in the current assessment dated 8/12/19 for individual 1. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The program specialist will Identify all information in section with bullet points to be readily available for staff and Support Coordinators to be able to identify |
04/01/2020
| Implemented |
| 6400.181(e)(13)(ii) | Progress in health motor and communication skills were not adequately discussed in the current assessment, 8/12/19, of individual 1. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The program specialist will Identify all information in section with bullet points to be readily available for staff and Support Coordinators to be able to identify |
04/01/2020
| Implemented |
| 6400.31(a) | The Thermostat located in the living room was locked and the individual or staff had no access to monitor and adjust the heat or cooling as needed. The key was not found on site during inspection. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.) | POC-Jami has requested that the landlord provide a key for the thermostat. |
04/01/2020
| Implemented |
| 6400.181(f) | There was no verification in record that assessment was sent to the team 30 days prior to Individual support plan meeting on 2/16/20. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist will provide all assessments accompanied with a verification cover sheet of date sent that will be submitted into service binders))The Program specialist will update google calendar to ensure that all assessments will be completed in the allotted time from 30-60days) |
04/01/2020
| Implemented |
| 6400.183(c) | There was no documentation of who participated in individual 1's individual plan meeting on 2/16/2020. | The list of persons who participated in the individual plan meeting shall be kept. | The program specialist will complete a packet checklist for content during the ISP meeting to ensure Jami has the documentation to include in service binders of meeting date with all signatures of individuals who participated. This signature page will be inserted behind the ISP of the consumer |
04/01/2020
| Implemented |