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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The written fire drill record for the fire drill held on 11/17/2023 did not include the amount of time it took for evacuation. The written fire drill record for the fire drill held on 1/25/24 did not include the exit route used, problems encountered, or if the smoke detectors were operable. | 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. | The Program Specialist and House Manager will be retrained on regulation 6400.112(c), 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.
The House Manager will also be retrained on the importance of accurately completing the fire drill and evacuation record, and well as reviewing the record for completeness and accuracy.
The Program Specialist will review the fire drill and evacuation record monthly to ensure compliance, completeness and accuracy. |
07/12/2024
| Implemented |
| 6400.112(e) | The most recent fire drill held during sleeping hours was 8/7/2023. | A fire drill shall be held during sleeping hours at least every 6 months. | The house manager and Program Specialist will be retrained on regulation 6400.112(e) , A fire drill shall be conducted during asleep hours every six months.
The asleep fire drill will be conducted by the House Manager between the hours of 11:00pm and 7:00 am every six months. The Program Specialist will ensure the compliance of this asleep fire drill by scheduling the asleep fire drill for the House Manger to implement. The Program Specialist will review the fire drill and evacuation record for accuracy and compliance. |
07/12/2024
| Implemented |
| 6400.112(f) | The front door was used as the exit route for the monthly fire drills held from 7/5/2023 through 6/12/2024. | Alternate exit routes shall be used during fire drills. | The House Manager and Program Specialist will be retrained on regulation 6400.112(f), alternate exit route shall be used during fire drills. The House Manager will ensure compliance by rotating all exit routes in the residence , using a different evacuation route each month. The Program Specialist will ensure the compliance of the House Manager by reviewing monthly the fire drill and evacuation record. |
07/12/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 5/14/23, at 8:13PM Individual #1 was near the refrigerator in the kitchen in the home. Direct Service Worker #1 was engaged in her cell phone while sitting on the couch in the living room of the home. Individual #1 and Direct Service Worker #1 began a verbal exchange and then Individual #1 approached Direct Service Worker #1. Individual #1 made two attempts to take Direct Service Worker #1's cell phone. Direct Service Worker #1 stood up and a physical altercation between Individual #1 and Direct Service Worker #1 ensued, lasting approximately 3 minutes. The physical altercation involved Direct Service Worker #1 pushing Individual #1 to the floor, grabbing Individual #1 by the shirt and hair and throwing an object at Individual #1. At approximately, 8:16PM, Direct Service Worker #1 departed the living room to the porch in the front of the home and interacted with a neighbor. Emergency Services were contacted, and the Police and an ambulance arrived at the home. Medical care was not provided to Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | 5/14/2023 , a physical altercation between Individual #1 and Direct Support Worker #1 ensued lasting approximately 3 minutes. The Direct Support worker #1 engaged with Individual #1 instead of separating from the situation. HNA recognizes the need for more extensive training for the staff
On 6/20/2023, all Direct Support Workers, supporting individual#1 will receive, Safe Crisis Management training. This training will be instructed by the Program Specialist. This training will be tailored to Individual #1
Prevention: Utilizing the proactive strategies, recognizing triggers and conditions as presented in Individual #1' s behavior support plan. De-escalation: How to properly respond to an individual in crisis by utilizing active listening skills, voice tone , body language and non-verbal cues. Management of the Crisis: strategies on dealing with the crisis ( changing task, possible removing the trigger, bargaining/negotiation) utilizing coping skills.
Recognizing the Cycle of Escalation: Knowing the individuals baseline behaviors, what are the stress responses that trigger behavior, bring the individual back to baseline after behavior. after successfully completing the 6 hour course, students will receive a certificate of completion for their training files. |
10/31/2023
| Implemented |
| 6400.80(b) | A six feet long by six-inch wide section of outdoor siding, on the driveway side of the home, was loose and protruding from outside wall of the home posing a free falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged, bricks and rocks, had vegetation growing through and leaning presenting a free falling and laceration hazards. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The outside of the building and the yard shall be well maintained, in good repair and free from unsafe conditions.
A 6 foot by 6 inch piece of outdoor siding, on the driveway side of the home was loose and could pose a free-falling risk due to a recent inclement weather. HNA's contractor was immediately contacted, and the outside 6 foot 6 inch piece of siding was repaired on 5/22/2023 and no longer a free-falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged rocks and bricks, had vegetation growing through areas and leaning presenting a free falling and laceration hazard. HNA's landscaping contractor was contacted immediately and construction on a new Versa Lok wall was scheduled to be installed on 7/12/2023.
The monthly site audit form was amended on page 7, Section 9 Outside, to reflect the inspection of all retaining walls to assure the wall / s are in good condition, as well as siding, gutters, rainspouts, sofit and facia are in good condition and not a free-falling hazard. |
06/30/2023
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #1, date of hire 10/25/22 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1. | The orientation must encompass the following areas: Job-related knowledge and skills. | HNA recognizes, Direct Service Worker #1 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1. On 5/19/2023 ,the House Manager immediately began to re-train the Direct Support Workers , working with Individual #1 on Individual #1's Behavior Support Plan . All DSWs working with Individual #1 were re-trained and completed a sign off sheet by 5/31/2023.The House Manager will onboard All Direct Service Workers prior to working with Individual #1 on Individual #1's " Getting to Know Me " book which encompasses Individual #1's ISP, Behavior Support Plan and synopsis of individual #1's like, dislikes, and needs. On going Training of individual #1's staff will consist of :The Behavior Specialist attending one house meeting every quarter. to review the Behavior Supports Plan and any changes made to the plan. As well as discuss any concerns from staff . |
07/01/2023
| Implemented |
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