| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certificate of compliance expires on 8/10/16. The agency completed a self-assessment of the home on 6/3/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Upon receipt of the certificate of compliance, Program Director will develop a timeline of tasks to be completed and share with all program staff via manager¿s and assistant manager¿s meetings and email alerts. Program Director will set deadlines for Program Specialists, medical personnel and HR to complete pre-inspection checklists (LICENSING INSPECTION INSTRUMENT SCORESHEET.) The Program Director will track completion of Pre-Inspection checklists and will file in PD office so they will be available to inspectors when they arrive. All Pre Inspection checklists will be completed 3-6 months prior to expiration listed on certificate of compliance. Program Director will assign Program Specialists group homes to inspect. [Immediately, the CEO will review the most recent Certificate of Compliance to determine the date the current license expires an develop and implement a tracking system to ensure the agency completed self-assessment 3 to 6 months prior to the expiration date of the Certificate of Compliance. Upon completion of the self-assessment, the CEO will review and cross reference with the expiration date of the Certificate of Compliance to ensure timely completion. Within 30 days of receipt of the plan of correction, the CEO will train all staff responsible of completing the self-assessments on the tracking system to ensure timely completion. Documentation of training shall be kept. (AS 11/8/16)]
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09/28/2016
| Implemented |
| 6400.112(d) | The fire drill held on 10/3/15 had an evacuation time of 8 minutes and 34 seconds. The fire drill held on 10/7/15 had an evacuation time of 3 minutes and 51 seconds. The fire drill held on 10/9/15 had an evacuation time of 2 minutes and 35 seconds. The fire drill held on 10/12/15 had an evacuation time of 2 minutes and 53 seconds. The home does not have an extended evacuation time specified in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Individuals receive Fire safety training upon admission and annually thereafter from a Program Specialist. Monthly Fire Drills serve as an ongoing assessment tool to determine if individuals are able to evacuate safely within the 2 ½ minute mark. If an individual fails to evacuate within the 2 ½ minutes allotted the team will work to determine the reason for the change and make adjustments to accommodate the individual¿s changing needs. The individual will be reeducated about fire safety if deemed necessary and the house staff will be trained on the changes in need for the individual. [(If needed and appropriate, the agency will work with the local Fire Department and secure an extended time for drills.) NOT ACCEPTABLE (AS 11/8/16)]The results of the ongoing assessment and each individual¿s needs are to be summarized on the evacuation plan for each house and within each individual¿s Support Plan completed by the Program Specialist. This information will be documented on the Fire Drill Report Form and turned in to Program Specialists as completed.
All agency staff receive fire safety training as part of orientation and annually thereafter. Resident Managers train new employees during in-house orientation on the evacuation procedures for the house, including the individual¿s abilities and need for help as well as the fire system specific to the site. When assigning staff to complete a fire drill they will be provided with guidelines/procedures to complete the drill, the most recent evacuation plan for the site and the procedure for the fire system check for the site. [Fire drills conducted between May, 2016 and August 30, 2016 were completed within the required 2 1/2 minutes. Within 30 days of receipt of the plan of correction, the program specialist(s) shall assess as per regulation 6400.181(e)(8) and train staff in all individuals' ability to evacuate in the event of a fire and identify specific assistance needed. Documentation of training shall be kept. Within 90 days of receipt of the plan of correction, the program specialist(s) shall observe a fire drill at each community home to ensure fire drills are conducted as required including all individuals evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert and documentation is kept as required. Immediately, and monthly for 3 months and then at least quarterly thereafter, the Program director will review a 25% sample of fire drill records to ensure fire drills are conducted and documented as required. Documentation of reviews shall be kept. (AS 11/8/16) |
09/28/2016
| Implemented |
| 6400.211(b)(1) | The emergency information for Individual #1 did not include the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | Individual Emergency Contact Information Sheets were developed for inclusion in Individual Records. All managers received a hard copy at the staff meeting on 7/26/15. Emergency Information sheets will be filed in individual house big books and in their charts in the office. Compliance will be ensured via completion of quarterly record audits. [Individual #1's emergency information was updated to include all required information. Within 30 days of receipt of the plan of correction and upon admission, the program director or designated management staff shall review all individuals' records to ensure all required information is included. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.211(b)(3) | The emergency information for Individual #1 did not include the name, address and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Individual Emergency Contact Information Sheets were developed for inclusion in Individual Records. All managers received a hard copy at the staff meeting on 7/26/15. Emergency Information sheets will be filed in individual house big books and in their charts in the office. Compliance will be ensured via completion of quarterly record audits.[Individual #1's emergency information was updated to include all required information. Within 30 days of receipt of the plan of correction and upon admission, the program director or designated management staff shall review all individuals' records to ensure all required information is included. Documentation of reviews shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |
| 6400.212(a) | Individual #1's record contained an ISP signature page and ISP planning documentation release for another individual. | A separate record shall be kept for each individual. | Historically, individual `Big Books¿ are checked once each year prior to inspection. Occasionally, paperwork can be misfiled. This process is being changed immediately to include quarterly audits of all individual¿s big books in the houses to ensure quality control. A CHART AUDIT form and process have been developed to address this issue and to formalize this process.
Big Book Record Sets have been established, distributed, and reviewed with all Residential Managers and Program Specialists. From this point forward, all house big books will be organized consistently. A chart audit form will be completed for each individual in our residential homes quarterly. Audits will be completed by managers and Program Specialists under the direction of the Program Director. [Within 30 days of receipt of the plan of correction, the program director shall train all staff persons responsible for the quarterly record audits of the policy and procedures to ensure all required information is present and a separate record is kept for each individual. (AS 11/8/16)] |
09/28/2016
| Implemented |