| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | On 06/24/2016, the staff ratio was 1:3 for approximately 4.5 hours due to a staff medical emergency. The staff ratio in the home in 2:3 | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | When an employee is unable to work or complete a scheduled shift, resulting in change in the staffing ratio and the required level of supervision for the home as documented in the consumers Individual service plan, the following procedure will be followed:
1. Staff must notify their immediate Supervisor of their anticipated absence or need to leave their work site, in accordance with the Staff Call out Policy, between the hours of 9a-5pm, Monday-Friday. If after business hours, contact the on-call personnel, which includes weekends and holidays.
2. Supervisor and or On-call personnel will make effort to arrange alternative staffing and cover the shift within 1 hour.
3. If, coverage is not secured within 1 hour, the Supervisor/On-call Personnel should go to the home and continue seeking coverage, while maintaining the staff ratio. |
12/08/2016
| Implemented |
| 6400.62(a) | Diamond Rock salt, Rug Doctor and Old English which indicated to contact poison control if ingested was found unlocked in the garage. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 12/07/2016 the diamond salt, rug doctor, and old English was immediately removed and locked away in a container away from common areas. Through training and monthly staff meetings, Program Specialist will reiterate to staff how to properly store poisonous materials.(All staff will be retrained n poisonous substances within 30 days of receipt of this plan. Residential manager will conduct weekly physical site visits to ensure poisonous substances are stored properly. DS 07.05.17) |
12/07/2016
| Implemented |
| 6400.66 | The light was inoperable in Individual # 1's bedroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Inoperable light in individual #1¿s bedroom was repaired on 12/8/16 (Please see attached). Moving forward monthly quality assurance visits will be completed by Program Specialists and Team Facilitators to ensure safety and avoid accidents. |
12/08/2016
| Implemented |
| 6400.112(c) | The fire drill record dated 10/21/2016 did not document the evacuation time. | 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. | A monthly fire drill record will be maintained by Program Specialists. Through training and monthly staff meetings, staff will be reminded on how to properly conduct a fire drill and fill out paperwork. |
12/08/2016
| Implemented |