| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.89(d) | The fire drill conducted 12/7/19 at 9:00 AM had an evacuation time of 3 minutes. The fire drill conducted 1/27/2020 at "13:30" had an evacuation time of 5 minutes. The agency does not have an extended evacuation time designated in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Our facility trains service dogs to perform several tasks, one of the tasks is pulling fire alarms on command. Our plan of correction is to notify all persons in the center that service dogs are being trained to pull alarms and they are to treat it as an emergency. [Immediately, the CEO or designee shall develop and implement policies and procedures to conduct fire drills to ensure all staff persons and individuals are able to evacuate the entire building within 2 1/2 minutes. Within 30 days of receipt of the plan of correction all staff person shall be educated on the aforementioned policies and procedures. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
03/06/2020
| Implemented |
| 2380.91(a) | Individual #1, date of admission 9/9/19, did not have fire safety training upon admission. | 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. | The facility is 7x24 and the individual was the only person at the facility in his time frame. His ISP states that he does not like the fire alarm and will try to get out of the building as fast as he can. He also needs prompts to help him and he will become aggressive if the sound bothers him. Since the individual is no longer at our facility, our correction plan going forward is to hold a fire drill once a month as we have, but we will do a drill during ATF hours. [Individual #1 was discharged on 4/2/20. Upon admission and annually, the CEO or designee shall ensure all individuals are instructed in fire safety as required and documentation is kept. The CEO or designee shall audit the documentation and interview the individual to ensure fire safety training is completed for all individuals, timely. Documentation of the audits and interviews shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
03/06/2020
| Implemented |
| 2380.111(a) | Individual #1's most recent physical examination was competed 2/7/19. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual's recent physical was requested from the SC and family and was submitted on 3/10/2020. [Individual was discharged on 4/2/20. Prior to admission and upon completion, the CEO or designee educated in the requirements of individuals' physical examinations, shall audit the physical examination documentation to ensure timely completion with required information and that all individual health services will be arranged and provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS 4/13/20)] |
03/10/2020
| Implemented |
| 2380.113(a) | Direct Services Worker #1, start date 9/9/19, does not have a physical examination. Program Specialist #3, start date 9/9/19, does not have a physical examination. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The DSW #1 and Program Specialist #3 will have their physicals and TB test as soon as they are allowed to go during the COVID 19 Crisis. I will put April 17as our correction date with intention of getting it sooner if probable.[Prior to hire and upon completion, the CEO or designee educated in the requirements of staff persons' physical examinations, shall audit the physical examination documentation to ensure timely completion with required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS 4/13/20)] |
04/17/2020
| Implemented |
| 2380.113(c)(2) | Direct Services Worker #1, start date 9/9/19, does not have a tuberculin evaluation. Program Specialist #3, start date 9/9/19, does not have a tuberculin evaluation. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant. | The DSW #1 and Program Specialist #3 were moved out of the facility until such a time that their physicals and TB test are updated. [Prior to hire and upon completion, the CEO or designee educated in the requirements of staff persons' physical examinations, shall audit the physical examination documentation to ensure timely completion with required information including Tuberculin testing completion. Documentation of the audits shall be kept. (DPOC by AES,HSLS 4/13/20)] |
04/17/2020
| Implemented |
| 2380.173(1)(ii) | The record for Individual #1 did not include identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The form we use was updated to include the area for identifying marks. [Individual #1's record was updated to include identify marks on 3/7/20. Individual #1 was discharged on 4/2/20. Upon admission of individuals and at least quarterly, the CEO or designee shall audit individual records to ensure all required information is included as per 2380.173(1)-(6). Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
03/06/2020
| Implemented |
| 2380.181(a) | The initial assessment for Individual #1, date of admission 9/9/19, was completed on 2/13/20. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | The timeliness of the assessment submission was overlooked due to our error. We submitted the assessment to the SC via email 2-13-2020. Individuals entering our program will have an assessment done in 60 days and the assessment will be forwarded to the plan team upon the completion of the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
02/13/2020
| Implemented |
| 2380.181(d) | Program Specialist #3 did not date Individual #1's assessment completed 2/13/20. | The program specialist shall sign and date the assessment. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.181(e)(8) | Individual #1's initial assessment, completed 2/13/20 did not include ability to evacuate in event of a fire. This section was blank. | The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.181(e)(9) | Individual #1's assessment, completed 2/13/20 did not include functional and medical limitations. This section was blank. | The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.181(e)(10) | Individual #1's assessment, completed 2/13/20 did not include a lifetime medical history. This section was blank. | The assessment must include the following information: A lifetime medical history. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.181(e)(11) | Individual #1's assessment, completed 2/13/20 did not a psychological evaluation. This section was blank. | The assessment must include the following information: Psychological evaluations, if applicable. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.181(e)(14) | Individual #1's assessment, completed 2/13/20 did not include the individual's ability to swim. This section was blank. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | The assessment form was updated to complete all blank sections. We sent emails to the family and/ or SC for information that they could add to the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/11/2020
| Implemented |
| 2380.21(v) | The facility did not keep a copy of the statement signed by Individual #1's, date of admission 9/9/19, acknowledging receipt of the information on individual rights. | The facility shall keep a copy of the statement signed by the individual or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The individual was in our facility before we were approved as an Adult Training facility and we overlooked the intake form information. The services for the individual have ceased. The facilities will update the intake form and it will have the information on individual rights appended and future individual's or their appointed legal guardian will sign the form which a copy will go into the individuals records. [Individual #1 was discharged on 4/2/20. Immediately, the CEO or designee shall develop and implement policy and procedures to ensure all individuals and persons designated by the individual and/or court appointed legal guardian are informed and explained individual rights and the signed statement is kept. Prior to admission of individuals, the CEO or designee shall train all staff persons on the aforementioned policy and procedures and individual rights and their responsibilities of ensuring individual are informed and explain individual rights. Documentation of the training shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
03/31/2020
| Implemented |
| 2380.36(a) | Program Specialist #3, start date 9/9/19, was not trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the facility, the use of fire extinguishers, smoke detectors, and fire alarms prior to working with individuals. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered. | Program Specialist #3 will attend our CERT Training which will include Fire Safety and will be trained on the facility evacuation and responsibilities during Fire Drills and actual emergencies. [Program Specialist #3 was trained in fire safety on 3/30/20. Immediately, and prior to hire and at least annually, the CEO or designee shall develop and implement policies and procedures to ensure all staff person are educated in fire safety with all required information as per 2380.36a. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
04/17/2020
| Implemented |
| 2380.37(a) | The training records for Direct Services Worker #1, start date 9/9/19 do not include the date of the training, the source of the training, the content of the training, or the length of the training. The training records for Chief Executive Officer #2, start date 9/9/19 do not include the date of the training, the source of the training, the content of the training, or the length of the training. The training records for Program Specialist #3, start date 9/9/19, do not include the date of the training, the source of the training, the content of the training, or the length of the training. | Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | Our training record summary sheet will be updated to include the information that is contained on the certificate. The certificates for the training will be kept with the summary sheet. [At least quarterly, the CEO or designee shall audit all staff person's training records to ensure all training records include the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
04/17/2020
| Implemented |
| 2380.38(a)(1) | Chief Executive Officer #2, start date 9/9/19, did not have an orientation within 30 days after hire. Program Specialist #3, start date 9/9/2019, did not have an orientation within 30 days after hire. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | The CEO created and submitted orientation training policies when we applied for licensing in 2016 but was not recorded or updated when we became an Adult Training Facility. The Program Specialist received orientation training when she was hired in 2019 but was not recorded or updated when we became an Adult Training Facility. Our plan of correction for orientation training is all employees will immediately receive updated orientation training and be required to sign acknowledgement forms. The signed forms will be entered into their training record. We will complete this task during the COVID 19 crisis. [Immediately, the CEO or designee shall develop and implement an orientation and training system to include required areas as per 2380.38(b)(1)-(5). Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all current staff and new staff on the aforementioned orientation and training and maintain documentation of the trainings with required information. At least quarterly for 1 year the CEO or designee shall audit all staff persons training records to ensure all staff person have the required orientation and annual training. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
04/17/2020
| Implemented |
| 2380.38(a)(3) | Direct Services Worker #1, start date 9/9/19, did not have an orientation within 30 days after hire. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Direct Services Worker #1 received orientation training when he was hired in 2017 but was not recorded or updated when we became an Adult Training Facility. Our plan of correction for orientation training is all employees will immediately receive updated orientation training and be required to sign acknowledgement forms. The forms will be entered into their training record. We will complete this task during the COVID 19 crisis. [Immediately, the CEO or designee shall develop and implement an orientation and training system to include required areas as per 2380.38(b)(1)-(5). Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all current staff and new staff on the aforementioned orientation and training and maintain documentation of the trainings with required information. At least quarterly for 1 year the CEO or designee shall audit all staff persons training records to ensure all staff person have the required orientation and annual training. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/13/20)] |
04/17/2020
| Implemented |
| 2380.181(f) | The program specialist provided Individual #1's, initial assessment, completed 2/13/20 to the plan team members on 2/13/20 for an annual ISP meeting held on 1/21/20. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The timeliness of the assessment submission was overlooked due to our error. We submitted the assessment to the SC via email 2-13-2020. Individuals entering our program will have an assessment done in 60 days and the assessment will be forwarded to the plan team upon the completion of the assessment [Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure individuals' assessments are completed, timely, with all required information and to ensure current assessments are provided to all individuals' plan team members, timely. Individual #1 was discharged on 4/2/20. (DPOC by AES,HSLS on 4/13/20)] |
03/18/2020
| Implemented |