| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Staff person #1's fire safety training was completed on 9/28/15. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff person #1 was verbally reminded to complete fire safety training within 365 days to ensure compliance with regulations. Going forward the Director, Case Management is making training a reoccurring agenda item for her monthly Program Specialist meetings. She will remind her staff at those meetings who is due the following month and monitor to ensure compliance. |
02/17/2017
| Implemented |
| 6400.46(i) | Staff person #1's most recent First Aid and CPR training was completed on 9/28/15. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff person #1 was verbally reminded to complete First aid and CPR training within 365 days to ensure compliance with regulations. Going forward the Director, Case Management is making training a reoccurring agenda item for her monthly Program Specialist meetings. She will remind her staff at those meetings who is due the following month and monitor to ensure compliance. |
02/17/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's annual physical examination, dated 9/12/16, did not contain information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (see attachment) |
02/13/2017
| Implemented |
| 6400.181(e)(14) | Individual #2's assessment, dated 3/3/16, did not document the individual's ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual #2's annual assessment was completed on 3/8/17 and now contains her ability to swim. (see attachment) Swimming abilities will be clearly stated in residential assessments going forward. |
02/28/2017
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not document hair color, eye color or identifying marks. Individual #2's record did not document hair color, eye color or identifying marks. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #1's assessment was revised to include hair color, eye color and identifying marks. Individual #2's annual assessment was completed on 3/8/17 and includes hair color, eye color and identifying marks. Going forward, this information will be included in all residential assessments. (see attachments) |
04/03/2017
| Implemented |