| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed on 8/1/16 did not include a written summary of corrections made to violations found during their self-assessment of the home. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The Program Specialist corrected the "Self-Inspection Tool" to include the score and the summary, see attachment #19.
Policy on the Self Assessment was developed, describing in detail the procedure for self-inspection and follow-up plan, attachment # 21.
Training conducted by the Program Specialist is documented on Attachment #22. |
01/06/2017
| Implemented |
| 6400.71 | The telephone number to the poison control center was not located on or near the telephone in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The Program Specialist posted the Police-Fire-Ambulance: 911, emergency phone number poster in the kitchen near the telephone, see attachment #14.
Program Specialist educated staff on "Emergency Telephone Number" policy, see attachment #15.
Attachment #16 is the documentation of the staff retraining. |
01/06/2017
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The program specialist updated the "Evacuation Plan" to include the distribution of duties, see attachment #12.
Staff were re-educated on the "Emergency Procedure Plan" attachment #11 and the "Evacuation Plan" attachment #12.
Documentation of retraining is Attachment #13.
Ongoing training will be conducted on hire and annually thereafter at mandatory in-service |
01/06/2017
| Implemented |
| 6400.112(h) | The fire drill records did not indicate if all individuals evacuated to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The program specialist revised the policy "Fire Drills" see Attachment #5.
The fire drill log was updated to include the meeting place, see Attachment #9.
The fire drill was completed on 12/9/2016 using the revised form. |
01/06/2017
| Implemented |
| 6400.113(a) | Individual #1 was living in his/her residence when the home received their license on 12/1/15. He/She did not receive general fire safety training until 9/1/16. | 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. | Who: The program specialist and director of human resources updated the policy on Fire Safety Training, Attachment #4, to include " Upon admission and annually every January".
What: Policy was revised.
When: Current resident was re-educated on fire safety training program. The training is documented in attachment #4.
The information presented to each resident is documented on Attachments #3 & 5.
Staff retrained on the resident fire safety training plan as documented on Attachment #6. |
01/06/2017
| Implemented |
| 6400.145(3) | The written emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | WHO: The program specialist and director of human resources updated the policy on the emergency medical plan, attachment #1.
What: The emergency medical plan was revised to include the link between the supervisor and the team leader. The team leader is now directed to call the supervisor on call in the event of a medical emergency
When and How: All staff were retrained on the revisions of the policy, see Attachment #2. Moving forward the emergency medical plan with new provision will be addressed in new employee orientation and part of our annual mandatory in-service training.
Dates: 1/3/2017 |
01/06/2017
| Implemented |