| 6400.112(e) | Per this site's fire drill records, the two most recent fire drills held during sleeping hours occurred on 11/04/2025 and 06/27/2026---more than 6 months apart. A fire drill that took place on 04/04/2026 was labeled as having taken place during sleeping hours; however, as it took place at 7:28am, it was actually outside of sleeping hours. A fire drill was not held during sleeping hours at this site at least once every 6 months as required. | A fire drill shall be held during sleeping hours at least every 6 months. | All fire drills during sleep hours will be done in November and May to ensure compliance. The next sleep hour fire drill will be completed in November 2026. |
07/31/2026
| Implemented |
| 6400.143(a) | Per Individual #1's Individual Record, this individual was seen for a gynecological examination on 02/26/2026; however, the individual refused the examination at the appointment. There was no documentation showing the continued attempts to train the individual about the need for health care following this refusal of health care found within the Individual Record as required. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 will receive education regarding the purpose and importance of the recommended gynecological examination, potential health risks associated with not completing recommended preventative care, and available options or accommodations that may assist the individual in completing the examination.
The individual's response to the education, including continued refusal or willingness to reconsider the examination, will be documented in the Individual Record on the updated medical appointment refusal form.
Continued attempts to educate Individual #1 regarding the recommended health care will occur and will be documented until the examination is completed, the health care provider determines that the examination is no longer recommended, or another clinically appropriate plan is established.
The Program Specialist will review Individual #1's medical record monthly to ensure that the required follow-up education and documentation are present.
Program Coordinators, Program Managers, and applicable direct-care staff will receive training regarding the agency's expectations for documenting refusals of health care, continued education following a refusal, and required follow-up. |
08/10/2026
| Implemented |