| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | ULTRA BRITE BRAND TOOTHPASTE, DERMASIL BRAND LOTION AND POWER STICK BRAND DEODORANT WHICH ALL INDICATED TO CALL POISON CONTROL IF INGESTED WERE FOUND UNLOCKED IN STORAGE BINS IN THE ACTIVITY ROOM. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 4/19/17 toiletry products that required notification of poison control if ingested were placed in a locked cabinet.
The Manager of Residential Services will conduct retraining with the Program Specialists and Residential Managers; the Program Specialists will retrain direct support staff to ensure that all toiletry products containing poisonous materials are kept lock when not in use. The residential staff will conduct daily site checks to ensure poisonous substance are locked and will document on daily log. The Residential Managers will also complete weekly checks to ensure poisonous substance are locked and will document on weekly checklists. The weekly checklist will be submitted to the Program Specialists for review on a weekly basis. If poisonous materials are found during the daily check, staff will return them to the locked cabinet immediately. |
06/02/2017
| Implemented |
| 6400.62(d) | A CAN OF CHEF BOYARDEE BRAND RAVIOLIS, NUTRI GRAIN BRAND BARS, AND 1 CUP OF NOODLES BRAND SOUP WERE FOUND IN A CABINET STORED WITH SPIC AND SPAN BRAND CLEANER, CLOROX BRAND WIPES, AND FABULOSO BRAND CLEANER IN THE ACTIVITY ROOM. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | On 4/19/17, poisonous materials were removed the cabinet and kept locked in a location separate from food.
The Manager of Residential Services will conduct retraining with the Program Specialists and Residential Managers. The retraining will focus on ensuring that all poisonous materials are kept separate and stored away from food, food preparation surfaces and dining surfaces. Staff will complete daily site checks to ensure that poisonous materials are kept separate from food, food surfaces and dining surfaces. The daily site checks will be documented on the daily log. The Residential Manager will complete weekly checks to ensure that poisonous materials are kept separate and stored away from food, food preparation surfaces and dining surfaces and document on weekly checklist. The weekly checklist will be submitted to the Program Specialists for review on a weekly basis. If poisonous materials are found to be stored near food or on food preparation or dining surfaces, staff will remove the poisonous materials from those areas immediately. |
06/02/2017
| Implemented |
| 6400.181(e)(14) | INDIVIDUAL #1'S ANNUAL ASSESSMENT DATED 07/15/2016 DID NOT DOCUMENT THE INDIVIDUAL'S ABILITY TO SWIM. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The agency has implemented the use of an electronic assessment form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in February 2017 and all staff have been trained on how to complete the form using our electronic records system. |
06/02/2017
| Implemented |
| 6400.186(c)(4)(iii) | THE STRATEGIES USED TO TRACK PROGRESS TOWARDS INDIVIDUAL #1'S OUTCOMES OF APPROPRIATE INTERACTIONS AND STABILITY REMAINED THE SAME OVER 2 PLAN YEARS AND A MODIFICATION WAS NOT REQUESTED. | The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. | The Manager of Residential Services will conduct retraining with the Program Specialists focused on the need for revision or modification of methods used in the implementation of individuals outcomes if progress in not noted over a significant period of time. The Program Specialist will ensure that there is supporting documentation of such revisions or recommendations made. The Program Specialists will submit revisions and recommendations completed together with supporting documentation to the Manager of Residential Services. |
06/02/2017
| Implemented |