| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(f) | Individual #1 is hearing impaired and there was no operable mechanism to notify the Individual when there is a fire emergency. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | On 11/8/2018, the Program Manager replaced the bed shaker that was not working with a working shaker.
Program Administrator completed training with Program Director and Program Coordinator on 12/12/2018.
Program Director/Program Coordinator will complete training with Program Managers/Site Supervisors regarding the new Fire Drill Record by 1/15/2019. The Fire Drill Record, in the Alerting Systems Review, each individual who has a bed shaker. When the fire alarm sounds, the staff will also indicate whether or not the bed shaker was operative. If any Alerting system is inoperative the direct care staff will contact the On Call supervisor. Upon repair, the repair date will be indicated on the Fire drill record. |
01/15/2019
| Implemented |
| 6400.168(a) | Staff #1 did not complete an onsite med observation before administering medication. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | On 11/6/2018, Medication Administration Trainer completed two observations of Staff #1 administered medications.
The Medication Administration Program¿s Summary and Certification/Annual Practicum Sheet for newly trained staff will be reviewed by the Human Resources Coordinator upon completion.
Monthly, the Medication Administration Program¿s Summary and Certification/Annual Practicum Sheets for all staff administering medications will be reviewed by the Human Resources Coordinator to ensure observations are completed. |
11/06/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment dated 4/20/18 did not include current level of performance and Progress in health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Program Coordinator edited the Individual¿s Assessment and included the level of performance and progress in the area of Health.
Program Administrator completed training with Program Coordinator on 12/06/2018.
Program Coordinator will submit the individual¿s assessment to the Program Administrator five weeks prior to the Annual Individual Support Plan meeting for review and approval. |
12/10/2018
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment dated 4/20/18 did not include current level of performance and Progress in motor and communication. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Program Coordinator edited the Individual¿s Assessment and included the level of performance and progress in the areas of Motor and communication skills.
Program Administrator completed training with Program Coordinator on 12/06/2018.
Program Coordinator will submit the individual¿s assessment to the Program Administrator five weeks prior to the Annual Individual Support Plan meeting for review and approval. |
12/10/2018
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's assessment dated 4/20/18 did not include current level of performance and Progress in activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Program Coordinator edited the Individual¿s Assessment and included the level of performance and progress in the are of Activities of Residential Living.
Program Administrator completed training with Program Coordinator on 12/06/2018.
Program Coordinator will submit the individual¿s assessment to the Program Administrator five weeks prior to the Annual Individual Support Plan meeting for review and approval. |
12/10/2018
| Implemented |