| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.87 | Staff #2 had fire safety training on 2/19/13 and not again until 2/26/14. Staff #1 had fire safety training on 2/14/13 and not again until 2/26/14. | Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept. | The Annual Fire Safety Training for these staff had to be rescheduled due to inclement weather. The next Fire Safety Training will be held in Jan. 2015 and again in June 2015. The training will then be held annually in June of each year to avoid winter weather. The Client Services Director will be responsible for scheduling this annual training to prevent this non-compliance from occurring in the future. |
11/04/2014
| Implemented |
| 2390.151(e)(5) | The assessment for Individuals #1, #2, and #3 did not state their ability to sef-administer medications. | The assessment must include the following information: The client's ability to self-administer medications. | Included is the assessment, completed since licensing, with their ability to self-administer medications (C2). The Program Specialist in the Cloister WAC was trained in her responsibility to assess this skill to prevent this from occurring in the future. The Program Specialist will be responsible for documenting this information. All files have been reviewed and the individuals' ability to self-medicate assessed. |
10/23/2014
| Implemented |
| 2390.151(e)(8) | The assessment for Individual #2 did not state her ability to evacuate in the even of a fire. It was left blank. | The assessment must include the following information: The client's ability to evacuate in the event of a fire. | Included is the assessment of another Individual (attachment C1) completed since licensing. His ability to evacuate in the event of a fire was assessed. The Cloister WAC Program Specialist was trained in her responsibility to assess this skill to prevent this from occurring in the future. The Program Specialist will be responsible for documenting this information. Individual #2's assessment was updated to include her ability to evacuate. |
10/14/2014
| Implemented |