| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Program Specialist #1 most recently had a physical examination completed on 4/28/17. Direct Service Worker #3 had a physical examination completed on 8/23/17 and then again on 10/22/19. [Repeat Violation-11/19/18] | 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. | Program Specialist #1 is scheduled for a physical exam on 11/18/19. A monitoring tool has been created for the Manager of Operations to utilize as a way to track all employee's annual requirements. Manager of Operations will notify employee that they need a physical at least 30 days prior to the expiration date. [Program Specialist #1 had a physical examination completed on 11/19/19. Immediately and upon completion the CEO or designee shall audit PS #1's physical examination and all other staff persons' current physical examination to ensure all required information is included, missing information shall be obtained immediately. Documentation of audits shall be kept. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff person have physical examinations completed, timely. (DPOC by AES,HSLS on 12/6/19)] |
11/14/2019
| Implemented |
| 6400.151(c)(2) | Program Specialist #1 most recently had a Tuberculin skin testing completed on 4/30/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Program Specialist #1 is scheduled for a TB test 11/18/19. A monitoring tool has been created for the Manager of Operations to utilize as a way to track all employee's annual requirements. Manager of Operations will notify employee that they need a physical at least 30 days prior to the expiration date. [Program Specialist #1 had Tuberculin testing completed on 11/21/19. Immediately and upon completion the CEO or designee shall audit PS #1's physical examination and all other staff persons' current physical examination to ensure all required information is included, missing information shall be obtained immediately. Documentation of audits shall be kept. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff person have physical examinations completed, timely. (DPOC by AES,HSLS on 12/6/19)] |
11/14/2019
| Implemented |
| 6400.15(b) | The agency completed the self-assessment on a Self Inspection/Declaration Tool, a document used for opening new homes. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The self assessment was redone on the correct tool; the Department's licensing inspection instrument. The Program Manager will complete self assessments 3-6 months prior to expiration of certificate on the Department's licensing inspection tool. The Director will review the tool and sign off after each inspection.[Immediately and upon completion, the CEO or designee shall audit all self-inspection completed for each home to ensure all regulations are addressed and all information is completed and there are not any areas left blank. (DPOC by AES,HSLS on 12/6/19)] |
11/08/2019
| Implemented |
| 6400.46(a) | Program Specialist #1, date of hire 2/5/18, did not have training in fire safety. Direct Service Worker #2 had training in fire safety on 4/5/18 and then again on 6/15/19. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Fire Safety Training has been scheduled for 12/6/19 with the Farrell Fire department for all employees to attend. An Orientation Training has been created for new hires which includes general fire safety training which will be completed by Program Manager and Program Coordinator. Fire Safety training will be scheduled annually for all staff with the Farrell Fire Department. The Manager of Operations will audit all new hire files within 30 days of hire to ensure all requirements have been met. [Program Specialist #1 had fire safety training on 11/24/19. (certificate of attendance provided to the Department. Direct Service worker #2 had orientation on 11/13/19, to include "general fire safety". Immediately, the CEO or designee shall ensure Direct Service Worker #2 and all other staff person have up to date fire safety training to include 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered and documentation is maintained. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all staff have orientation and required staff trainings completed, timely. (DPOC by AES,HSLS on 12/6/19)] |
11/15/2019
| Implemented |
| 6400.51(a)(3) | Direct Service Worker #2, date of hire 1/8/19, did not complete orientation. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | An Orientation Training was developed after Direct Service Worker #2 was hired. Direct Service Worker #2 has completed Orientation again on 11/13/19 to ensure he meets Orientation Training Requirements. All new hires will complete the Orientation Training as described in subsection (b) before working alone with individuals. The Manager of Operations will complete a chart audit at 10 days of employment to ensure the new hire file is complete and the employee has completed the Orientation Training. [Documentation of the audit shall be kept. (DPOC by AES,HSLS on 12/6/19)] |
11/13/2019
| Implemented |