| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff # 4 completed fire safety training on 4/20/16 and it was not conducted by a fire safety expert | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | All supervisors will be trained by a fire safety expert on 9/8/2016. All supervisors will be training staff at there staff meetings.[Quality Manager/Program Designee will ensure that all staff receive annual fire safety training by a safety expert. Additionally, a tracker will be utilized to ensure that each staff receives the training timely. Program director/program designee will complete quarterly audits of the tracker, its accuracy, completion and ensure that information is being relayed to directors timely. The process will begin within fifteen days of receipt of this plan of correction DD 9.20.16] |
10/14/2016
| Implemented |
| 6400.62(a) | Listerine total care which indicated to contact poison control if ingested was found unlocked in the main bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Listerine was placed in a locked cabinet in the home immediately. The supervisors of the home (Tammy Klinger and Carmon Davis) will monitor the home daily to make sure the Listerine is not left out. (All items with labels that list to call poison control if ingested will be locked in homes where individuals can not differentiate poisons from other substances.) |
05/13/2016
| Implemented |
| 6400.62(c) | There was an unlabeled bottle containing a clear substance found under the sink in the kitchen that staff identified as ¿Windex¿. | Poisonous materials shall be stored in their original, labeled containers. | Staff will not put unknown substances in unidentified bottles. Supervisor's of the home will monitor this to make sure it is not being done and is locked up. (All items with labels that list to call poison control if ingested will be locked in homes where individuals can not differentiate poisons from other substances. All cleaning and related items in the home will be kept in their original containers). |
05/19/2016
| Implemented |
| 6400.64(c) | There was a brownish substance splattered on the door designated as a staff room. | Trash shall be removed from the premises at least once per week. | The brownish substance was high up on a wall. The assistant Residential Director (Laura McGinty) stood on a chair and cleaned the substance off on site of the inspection. Staff in the home will make sure that the walls are clean. Supervisors of the home (Tammy Klingler and Carmon Davis) will monitor. |
05/19/2016
| Implemented |
| 6400.113(a) | Individual # 3 completed fire safety training on 9/9/15 and it was not conducted by a fire safety expert. | 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. | All supervisors are being trained by a fire safety expert on 9/8/2016. The supervisors will be training staff and individuals. |
10/14/2016
| Implemented |
| 6400.141(c)(4) | On individual #4's annual physical exam dated 9/8/15 the physician noted that the findings were not normal due to cerumen impaction and did not document if further evaluation was needed by a specialist | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Amy Fritts (program specialist) will receive all documentation from medical appointments. Amy will review the paper work and notify the correct party in ensuring the documentation is completed. |
08/17/2016
| Implemented |