| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #2 was required to pay a twenty five dollar fee for a missed doctor¿s visit at Lifepath with Dr. Soloway on 5/12/15. | Individual funds and property shall be used for the individual's benefit. | Individual #2 was reimbursed the twenty five dollars for the missed appointment during the survey. Effective immediately, all staff will follow the clients funds policy to protect the individuals funds and be used for the individuals benefit. Any issues or questions that arise from the financial department will be addressed with the Director of Community Programs for discussion. |
07/01/2016
| Implemented |
| 6400.46(i) | Staff #2 did not complete CPR training. | 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 #2 completed CPR training on 4/27/2016. 1. All employees, full, part time, and PRN employed by Divine Providence Village shall be responsible for attending a minimum of 24 hours of staff development and training per training year. The calendar year will run from January through December.
2. New Employee Orientation: Prior to working, all new hires will attend New Employee Orientation. This training will be provided for staff persons relevant to their job responsibilities, regulations and policies and procedures of the program to which they are assigned.
a. New employees will be expected to participate in a combination of classroom training and site specific training during their orientation period
b. The Administrator, in conjunction with the Department Head, may approve a modified orientation schedule.
c. Continued employment is contingent upon successful completion of all competency based trainings presented in New Employee Orientation.
3. Site Specific Training: All employees will participate in site specific training. This training will be specific to daily operations of any department
a. Site specific training will be conducted departmentally. Times may fluctuate to accommodate the schedule for which the new employee has been hired
b. Site specific training will focus on skills and competencies necessary to fulfill the job duties assigned as outlined in the job description provided to each employee.
c. Site specific training will be conducted by the new employee¿s immediate supervisor in conjunction with the training department.
d. Completed documentation of site specific training will be forwarded to the designated member of the administrative team for review.
e. Records of site specific training will be maintained in employee files within the training department and will be recorded in the Training Database.
4. All staff are required to have 24 hours of training annually. CPR and PEI Training as required by their position and job description.
a. If staff scheduled to attend a specific training day are unable to do so they are responsible for following proper call out procedures and to notify the Training Department. Failure to do so will result in corrective action.
b. Progressive disciplinary action for failure to meet annual training requirements will remain active in employee file for a period of two (2) years.
c. Individuals failing to successfully complete competency based trainings will be given 30 days to prove competency. If competency cannot be demonstrated employment will be terminated.
d. Credit may be given for trainings conducted by other agencies/entities. Trainings submitted for approval must be related to the staffs¿ current position. Staff are required to submit proof of training for review and acceptance by the Director of Training.
5. Staff are required to maintain current certification in CPR/AED and First Aid as required by their position and job description.
a. Staff obtaining certifications from other employers may present proof of current certification to the training department for approval.
b. All staff will be required to attend annual CPR/AED/ First Aid refresher classes in addition to the bi-annual certification requirements set forth by American Red Cross and American Heart Association
c. All nursing staff will maintain certification in the professional rescuer CPR/AED (BLS)
6. All staff will be responsible for completing those trainings specific to the regulatory agency overseeing the program to which they are assigned. These trainings are outlined in the Training Policy Appendix.
7. All original training records will remain on file within the training department and will be recorded in the Training Database. |
07/01/2016
| Implemented |
| 6400.62(c) | A white powdery substance consistent with laundry detergent was found in a clear unlabeled container in the hallway closet. | Poisonous materials shall be stored in their original, labeled containers. | The white powdery substance was determined to be laundry detergent. The laundry detergent was discarded. Effectively immediately all poisonous materials are stored in their original labeled containers. Site Managers perform monthly physical site checks for poisonous materials to ensure they are kept in their original containers. These items are reported to the Director of Operations. |
07/01/2016
| Implemented |
| 6400.76(a) | The Seat on a blue chair located in the basement was broken. | Furniture and equipment shall be nonhazardous, clean and sturdy. | This chair has been removed from the residence. The site Managers complete monthly audits and report any piece of property that is considered hazardous, unclean or not sturdy to the Director of Operations and have it removed from the facility. |
07/01/2016
| Implemented |
| 6400.110(e) | The smoke detector in the attic was inoperable. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The smoke detector was replaced during the survey. Besides during monthly fire drills (where all detectors are checked by staff), the maintenance department complete monthly checks of all fire systems. Any issues noted with each smoke detector is addressed through the maintenance department and fire monitoring company and written documentation is kept on file. |
07/01/2016
| Implemented |
| 6400.112(c) | Fire drill records for the home from 4/1/15 to 4/1/16 did not document if the fire alarm or the smoke detector were operable. | 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. | The Fire Drill Policy and Procedure (including the fire drill document) was revised to include that all smoke detectors are checked for operation during the time of the drill. Site Managers were trained and they trained the staff at each of the homes. The Fire drills are reviewed by the site manager within 24 hours of the drill, then forwarded to the Director of Operations with 48 hours for review and then forwarded to the Director of Maintenance. Any issues noted with each smoke detector is addressed through the maintenance department and fire monitoring company and written documentation is kept on file. |
07/01/2016
| Implemented |
| 6400.141(c)(15) | Individual #2¿s most recent physical dated 9/8/15, did not document special diet instructions | The physical examination shall include:Special instructions for the individual's diet. | Individual's #2 had a recent physical dated 9/22/2016. the diet instructions include: House Diet, assist with cutting food and supervision at meals. The Healthcare Coordinator reviews all physicals completed to ensure Diet is listed on the physical and any special instructions are carried out by staff through the training record. |
10/01/2016
| Implemented |
| 6400.151(c)(1) | Staff #1¿s physical dated 11/14/14 specifically documented that it was not a general physical. | The physical examination shall include: A general physical examination. | Employees must have a new physical and PPD [or chest X-Ray] completed every two years. It is the responsibility of the Workers¿ Compensation, Leave Management, and Credentialing Specialist in the HR Department to keep an accurate, up to date list of all employees of DPV have their clearance and physical due dates. Employees and their supervisors are notified of upcoming clearance and physical due dates two to three months in advance. Employees who do not complete their clearance[s] or physical by the due date are removed from the schedule until we receive the required clearance[s] or physical. All documents are kept in the permanent personnel file. If remediation needs to occur once the staff turn in their items, the HR Specialist will notify the employee and manager and the employee will not be placed on the schedule until remediation is completed. |
07/01/2016
| Implemented |
| 6400.181(e)(13)(viii) | individual #2¿s most recent assessment dated 10/23/15 did not document progress and growth progress in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Effective 7/1/2016 a new assessment was initiated and the individuals Progress and growth in the managing of personal property is addressed and will be updated yearly within the ISP by the Program Specialist. |
07/01/2016
| Implemented |