| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff # 5 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). | Pam Hoffman (Residential Director) will obtain and keep on file the fire safety expert's certification. The staff will be trained annually. (New Staff will be trained as part of their orientation) |
08/17/2016
| Implemented |
| 6400.113(a) | Individual # 1 completed fire safety training on 4/20/16 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. | Pam Hoffman (Residential Director) Will obtain a copy of the fire safety expert's certification and keep it on file. (A schedule will be kept to ensure that each individual is trained on an annual basis and newly accepted individuals will be trained upon admission) |
08/17/2016
| Implemented |
| 6400.185(b) | Individual # 1's three month ISP review documentation dated 09/22/15 through 01/04/16 was not implemented by the ISP start date of 09/30/016. | The ISP shall be implemented as written. | Pam Hoffman (Residential Director will ensure that the program specialist stays within the 3 month reporting period. See attachement's #1 and #2 for the corrected documentation. The program specialist ( Amy Fritts) will ensure the ISP is implemented by the start date of the ISP. [All staff will receive training on the importance of quarterly ISP reviews and the time lines required by the regulations, within 30 days of receipt of this plan of correction. SW 1.5.17] |
08/17/2016
| Implemented |
| 6400.186(a) | Individual #1's three month ISP review documentation dated 6/9/15 through 9/21/15 and 9/2/15 through 1/4/16 covered a period greater than three months. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Pam Hoffman (Residential Director will ensure that the program specialist stays within the 3 month reporting period. See attachement's #1 and #2 for the corrected documentation. [All staff will receive training on the importance of quarterly ISP reviews and the time lines required by the regulations, within 30 days of receipt of this plan of correction. SW 1.5.17] |
08/17/2016
| Implemented |
| 6400.186(b) | Individual # 1's three month ISP review documentation dated 3/9/15-6/8/15 was signed on 3/9/15. Individual # Individual #1's three month ISP review documentation dated 6/9/15-9/21/15 was signed on 6/9/15. Individual # 1¿s three month ISP review documentation dated 9/22/15-1/4/16 was signed on 9/22/15. Individual # 1's three month ISP review documentation dated 1/5/16-4/4/16 was signed on 1/5/16 | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Pam Hoffman (Residential Director will ensure that the program specialist stays within the 3 month reporting period. See attachement's #1 and #2 for the corrected documentation.[All staff will receive training on the importance of quarterly ISP reviews and the time lines required by the regulations, within 30 days of receipt of this plan of correction. SW 1.5.17] |
08/17/2016
| Implemented |