| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | There is not written documentation that the furnace was inspected or cleaned. | 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.
| Furnace was inspected on 8/13/14. [Annual inspections will be scheduled in advance of the 365 day timefram to ensure that compliance is met. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.111(f) | The fire extinguishers located throughout the home do 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. | Extinguishers were inspected and tagged on 8/13/14. [Fire extinguishers will be scheduled to be inspected in advance of every 365 days to ensure that compliance is met. The house supervisor will check the fire extinguishers in all community homes monthly to ensure that they are tagged as inspected within the past year. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination, completed 7/8/14, did not indicate if Individual #1 was free of communicable disease. | 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. | Physical form was resubmitted to doctor on 8/15/14. When form is returned to KZL will send to Nancy Armstrong via email & fax. [Physical form has been obtainedd by the physician and now indicates that the individual is free of communicable disease. The program specialist will audit all physical examination forms to ensure they contain all of the required information. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.151(a) | Staff Person #1, hired 4/15/14 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Physical & TB completed will send to Nancy Armstrong via email and fax by 08/18/2014. [All staff persons physical examination forms will be reviewed monthly to ensure they were completed timely and contain the required regulatory information. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.168(e) | There was no documentation of the date and location of the medication administration training for the trainer. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | Documentation for med trainer was received on 8/5/14, and was sent via email to Nancy Armstrong 08/05/2014. Will send to Nancy via fax 08/18/2014. |
08/18/2014
| Implemented |
| 6400.181(e)(2) | Individual #1's assessment, dated 4/28/14, did not include likes, dislikes, or interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Was sent to Nancy Armstrong via email 08/04/2014. Will send via fax 08/18/2014. [Program Specialist will monitor individual records monthly to ensure that they contain the required information including the likes and disklikes of the individual. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.181(f) | The program specialist did not provide the assessment to the SC or plan team members prior to Individual #1 annual update meeting to be held 8/25/14. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Assessment sent to ISC on 8/15/14. [Form developed to track that assessment was sent to SC and plan team members. Program Specialist will audit individual records monthly to ensure they contain the required information including documentation that assessment was sent to SC and plan team members. (CHG 8/22/14)] |
08/18/2014
| Implemented |
| 6400.213(10)(iv) | Individual #1's record does not include a notice that the plan team members may decline the ISP review documentation. | Documentation of ISP reviews and revisions under § 6400.186 (relating to ISP review and revision), including the following: Notices that the plan team member may decline the ISP review documentation. | Form was sent to Nancy Armstrong via email 08/04/2014. Will fax 08/18/2014. [Form to document the offer of declination was developed. The program specialist will audit all individual records monthly to ensure they contain the required information. (CHG 8/22/14)] |
08/18/2014
| Implemented |