| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace of the home was inspected 1/3/20 and then again 4/18/21. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Tucker Family Supports supervisors will schedule furnace inspections 2 months before the prior annual inspection completed by a professional furnace cleaning company. Written documentation will be kept of review by residential supervisor. |
07/17/2021
| Implemented |
| 6400.111(c) | On 4/28/21 at 9:20 AM, the fire extinguisher located in the kitchen had a rating smaller than 2A-10BC. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | On 4/28/2021 auditors made Tucker Family Supports (TFS) aware that the fire extinguisher that was located in the dining room was too far away from the kitchen. On the evening of 4/28/2021, TFS moved the fire extinguisher on the wall into the kitchen location. |
04/28/2021
| Implemented |
| 6400.111(f) | On 4/28/21 at 9:20 AM, the fire extinguisher located in the kitchen was not inspected and approved by a fire safety expert. This extinguisher did not have a date of inspection. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | All fire extinguishers in the residential were inspected and approved by a fire safety expert with an inspection tag located on the extinguisher. The date of extinguisher is marked on the tag. |
05/01/2021
| Implemented |
| 6400.112(c) | The fire drill held on 10/28/20 does not include exit route used. The fire drill held on 4/14/21 does not include the amount of time it took for evacuation. | 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. | On 4/29/2021, 5/5/2021, Tucker Family Supports staff and house supervisor were retrained on fire safety documentation and evacuation by a safety expert. Tucker Family Supports updated the evacuation form to monitor ongoing compliance with a regulatory requirement with 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. |
05/01/2021
| Implemented |
| 6400.112(d) | The fire drill held on 9/4/20 had an evacuation time of 2 minutes 43 seconds. The fire drill held on 10/28/20 had an evacuation time of 2 minutes 35 seconds. The fire drill held on 2/2/21 had an evacuation time of 2 minutes 35 seconds. The fire drill held on 3/16/21 had an evacuation time of 2 minutes 56 seconds. | 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. | Tucker Family Supports (TFS) staff has been retrained and educated on the evacuation time and limitations with a fire safety expert on 5/15/2021. A fire drill will be conducted and timed by local fire safety expert. |
05/15/2021
| Implemented |
| 6400.113(a) | Individual #1, date of admission 7/1/20, received training in general fire safety on 7/29/20. | 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. | Tucker Family Supports Fire Safety Policy has been updated to include initial fire safety orientation for all residential clients. Staff are to conduct a fire safety review with clients upon initial admission. |
07/19/2021
| Implemented |
| 6400.141(c)(6) | Individual #2's physical examination completed 11/13/20 does not include Tuberculin skin testing by Mantoux method with negative results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Tucker Family Supports physical examination form has been updated to include all immunization information and results for all individuals admitted to the residence. |
05/05/2021
| Implemented |
| 6400.141(c)(10) | Individual #2's physical examination completed 11/13/20 does not include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 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. | Tucker Family Supports (TFS) updated the staff and consumer physical form to properly document immunizations as well as communicable diseases and included specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. |
05/05/2021
| Implemented |
| 6400.141(c)(11) | Individual #2's physical examination completed 11/13/20 does not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Tucker Family Supports physical exam form has been updated to include present health maintenance care required by the client such as medication, special diet, exercises, immunizations, or other preventative health care such as routine blood work. |
05/05/2021
| Implemented |
| 6400.141(c)(12) | Individual #2's physical examination completed 11/13/20 does not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | Tucker Family Supports physical examination form has been updated to include physical limitations of the individual. |
05/05/2021
| Implemented |
| 6400.141(c)(13) | Individual #2's physical examination completed 11/13/20 does not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Tucker Family Supports physical examination form has been updated to include allergies or contraindicated medications. |
05/05/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 6/16/20 and Individual #2's physical examination completed 11/13/20 do not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The TFS physical examination forms have been updated to include pertinent medical information relative to diagnosis and treatment in case of an emergency. |
05/05/2021
| Implemented |
| 6400.141(c)(15) | Individual #2's physical examination completed 11/13/20 does not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Tucker Family Supports physical examination form has been updated to include special instructions for the individual's diet. |
05/05/2021
| Implemented |
| 6400.181(e)(10) | Individual #1's assessment completed 7/1/20 and Individual #2's assessment completed 10/20/20 do not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The client's assessment form has been updated to include a lifetime medical history. |
05/05/2021
| Implemented |
| 6400.181(e)(11) | Individual #1's assessment completed 7/1/20 does not include a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The client's assessment has been updated to include his psychological evaluation. |
05/05/2021
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment completed 7/1/20 and Individual #2's assessment completed 10/20/20 do not include do not include the individual's progress over the last 365 calendar days and current level in the following areas: Health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The client's assessment has been updated to the the individual's progress over the last 365 calendar days and current level in the following areas: Health. |
05/06/2021
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's assessment completed 7/1/20 and Individual #2's assessment completed 10/20/20 do not include the individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The client's assessment has been updated to the individual's progress over the last 365 calendar days and current level in the following areas: recreation. |
05/06/2021
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's assessment completed 7/1/20 and Individual #2's assessment completed 10/20/20 do not include the individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The client's assessment has been updated to the individual's progress over the last 365 calendar days and current level in the following areas: financial independence. |
05/06/2021
| Implemented |
| 6400.213(1)(i) | Individual #1 and Individual #2's records did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | TFS supervisor updated each individual's record binder to include the following their personal information, including: their name, sex, admission date, birthdate and Social Security number. |
07/20/2021
| Implemented |