| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | Results-Self-Assessment-The self-inspection was completed on 2/18/20, but does not contain a written summary of corrections made. The violations are written out, but there is no POC indicated. | 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.
| 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team.
2. A Self-Assessment binder was assembled and each site has it's own section.
3. All Program specialists were trained/retrained on the purpose of the self-assessment, how to complete and where they will be kept on 3/12/2020.
4. Self-assessments will be completed in January and July of every year. This will be scheduled by the Compliance Officer (hired 7/28/19) and completed as a group with assistance. |
03/12/2020
| Implemented |
| 6400.72(b) | Screens in good repair-There is a screened in area off to the left side of the front door where the screen is torn in approximately six places and has holes. | Screens, windows and doors shall be in good repair. | 1. Maintenance removed the screen in the outdoor frame on 3/12/2020. It is not going to be replaced as it is not necessary. |
03/12/2020
| Implemented |
| 6400.77(a) | First Aid Kit-The first aid kit in the home was missing the following items: scissors, tweezers, and thermometer. | A home shall have a first aid kit. | 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team.
2. Scissors and tweezers were added to the first aid kit on 3/3/2020.
3. All Program specialists were trained/retrained on on first aid kit contents on 3/12/2020.
4. On 4/3/2020, the Fire drill log was updated to include a review of the first aid kit and its contents on a monthly basis. This implemented in April 2020. |
04/03/2020
| Implemented |
| 6400.104 | Notification-There is no notification to the fire department; the record contains a computerized drawing of the home that includes the locations of three women's bedrooms, currently only one man resides in the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team.
2. February 25, 2020, the Fire department was notified.
3. A move guide was developed in 2015 and available for all Program Specialists to follow when a resident moves in or out.
4. All Program specialists were trained/retrained on on notification of fire department on 3/12/2020. |
03/12/2020
| Implemented |
| 6400.112(a) | Fire Drills-No fire drill completed the month of April 2019, December 2019, or January 2020. | An unannounced fire drill shall be held at least once a month. | 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team.
2. All Direct Support Professionals were trained/retrained on Fire Safety and the requirements of fire drills on 3/11/2020.
3. All Program specialists were trained/retrained on on 3/12/2020 and Site Coordinators on 3/13/2020 on the requirements of fire safety.
4. Program Specialists are responsible for reviewing and signing all fire drills. If there are issues with meeting regulations, the corrective action will be filed with the failed drill. |
03/13/2020
| Implemented |
| 6400.112(c) | Fire Drill Record-No indication on 11/12/19 fire drill that the alarm was operational or tested. 5/15/19 fire drill does not indicate what time it was attempted or the amount of time it took the individuals to evacuate. The 6/4/19 fire drill record does not indicate the amount of time it took the individuals to evacuate. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team.
2. All Direct Support Professionals were trained/retrained on Fire Safety and the requirements of fire drills on 3/11/2020.
3. All Program specialists were trained/retrained on on 3/12/2020 and Site Coordinators on 3/13/2020 on the requirements of fire safety.
4. Program Specialists are responsible for reviewing and signing all fire drills. If there are issues with meeting regulations, the corrective action will be filed with the failed drill. |
03/13/2020
| Implemented |
| 6400.32(r) | Lock Bedroom Door-There is locking mechanism on Individual #1's bedroom door for privacy. | An individual has the right to lock the individual's bedroom door. | 1. Developed bedroom door lock education/determination/condition form to be completed for each individual. This is to be completed by 4/17/20.
2. Door locks will be installed on individuals' bedroom doors as soon as COVID-19 protections are lowered and visitation to homes is safer. Anticipated installation date by 6/30/2020. |
06/30/2020
| Implemented |