| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(a) | On 3/2/22, Orientation fire safety training sign in sheet and curriculum | 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 7 orientation fire safety training sign in sheet and curriculum was corrected on 12/24/2022.
This violation is a duplication of Martins Mill B violation 2 attachment#33. |
12/24/2022
| Implemented |
| 6400.46(a) | On 6/22/21 , staff 7 Orientation fire safety training sign in sheet and curriculum | 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. | The site specific orientation fire safety training sign in sheet and curriculum was completed on 12/24/2022. See violation 2 attachment # 42. |
12/24/2022
| Implemented |
| 6400.51(b)(3) | Staff 6 was hired 2/28/22 and did not receive orientation within 30 days of hire and working with individuals in individual rights. The first training in individual rights was on 7/29/22. | The orientation must encompass the following areas: Individual rights. | Staff 6 received her orientation training on 2/28/2022 which was within 30 days of hire before working with the individuals. See violation 3 attachment#43. The training in individual rights on 7/29/2022 was part of staff 6 annual training assigned in Relias. This document was made available during the inspection on 12/13/2022. |
12/13/2022
| Implemented |
| 6400.52(a)(1) | Staff 7 has 21.25 training hours for the 5/20/21 through 5/19/22 training year, instead of the 24 hours required. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | This violation was corrected on 12/20/2022 and is a duplication to Martins mill B, see Violation 3. See attachment#34. |
12/20/2022
| Implemented |
| 6400.52(c)(6) | Staff 7 has not received training in implementation of the individual plan for the 5/20/21 through 5/19/22 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff 7 as titled received her annual training in implementation of the individual plan for the 5/20/21 through 5/19/2022 training year. corrected on 12/20/2022. This violation as a duplication of Martins Mill B. See Violation 4 attachment #35. |
12/20/2022
| Implemented |
| 6400.169(a) | Staff 7 Medication training practicum last completed 5/15/21, only documentation of new practicum is observations checklist showing 2 observations done on 5/15/22. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | This violation is a duplication of Martins mill B, violation#9, attachment#40. Additional medication administration practicum observation was completed on 1/27/2023. |
01/27/2023
| Implemented |