| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The Fire drill dated 1/25/2021 for 928 Lindale street exceeded 2.5 minutes, at 3 minute total time. A subsequent drill in the same month was not completed. | 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 staff administering the training was retrained on 5/12/21 (Supporting Document #12). The fire drill form was also revised to highlight the required timeframe (Supporting Document #9). |
05/12/2021
| Implemented |
| 6400.113(a) | Fire safety training was not completed upon admission, There was no documented fire safety training for individual 1. | 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. | Upon starting, the Director of Residential recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. |
04/01/2021
| Implemented |
| 6400.141(a) | A current physical exam for individual 1 was not available at time of inspection. The last physical exam was completed on 11/18/2019. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | A physical for this individual was completed on 3/30/21 (Supporting Document #10 |
03/30/2021
| Implemented |
| 6400.144 | Vision exams for individual 1 are not kept current. Recommended for every 6 months on previous vision exam, more than 6 months have lapsed between vision exams. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| A vision exam for this individual was completed on 5/4/21 (Supporting Document #11). |
05/04/2021
| Implemented |
| 6400.181(a) | Only assessment available is dated 3/4/21, there was no documentation that the assessment was completed on an annual basis for individual 1. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Upon starting, Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. |
04/01/2021
| Implemented |
| 6400.34(a) | Verification that individual rights were reviewed annually with individual 1 was not was received. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Upon starting, Director recognized fire training, human rights, and assessments were out of date. Director completed all of this documentation in March of 2021. |
04/01/2021
| Implemented |
| 6400.165(c) | Flonase was not administered from March 1-20 for individual 1. Flonase was misplaced by individual while on a previous home visit per agency statement and not available to be administered. | A prescription medication shall be administered as prescribed. | Medication was procured from pharmacy and administered. Error was also entered into EIM. |
05/03/2021
| Implemented |