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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment completed 1/4/21 did not include a written summary of corrections. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| All self-assessments will be updated with the written corrective measures taken for each citation. This will be completed by 5/31/21. Directors, PDs, Managers and Specialists will schedule events and alerts in Google Calendars by 5/31/2021 to indicate the start and completion dates for the annual self-assessments, which will be completed 3-6 months prior to the license date of 5/13. The start date will be 11/13/2021 and the completion date will be 2/12/2022. Each event will be set to repeat annually. Upon completion of self-assessments and prior to the due date of 2/12/2022, PDs will schedule a meeting with the Managers and Specialists to review the self-assessments and plans of correction to ensure the plan of correction is written in the self-assessment. All PDs, Managers and Specialists will be retrained in the requirement to include written plans of correction in the self-assessment by 5/31/21. |
05/31/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(b) | Staff #5 completed fire safety training 05/21/18 and not again until 06/06/19. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | A staff other than staff #5 completed fire safety training on 7/9/18 and 7/8/19. See Fire Safety
Training Sign in sheets. All program staff are responsible for maintaining training
requirements and are expected to respond to the alerts generated by our training
software by registering and attending training. Employee failure to meet the
training requirements of their positions will be subject to corrective action and
may not be permitted to work until the requirements are met. Prior to a scheduled
leave of absence, employees will review training requirements coming due during
the leave of absence and employees will arrange with their supervisor to complete
the training in advance of their leave. On a monthly basis, Managers will review
the Monthly Certification Report provided by Human Resources with each of the
supervisors during supervision meetings, to discuss each employee¿s
registration, schedule and attendance at required trainings. Supervisors will
follow-up with employees to confirm registration and attendance in the
appropriate courses to maintain their requirements to continue working. All
employees will be retrained in the training requirements by 6/30/2020. A quarterly
review of a sample of employee training records will be completed by the PDs to
be held in July, October, January and April. A tool for completion of the quarterly
review will be developed by 06/15/2020 and PDs will be trained in the tool by
6/30/2020. Directors will review the outcomes of the quarterly sample reviews by
the end of July, October, January and April to determine any necessary
improvements in processes and training tracking. |
06/30/2020
| Implemented |
| 6400.46(d) | Staff #3 was trained in cardio-pulmonary resuscitation (CPR) on 04/06/17 and not again until 05/20/19. | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | A DSP staff other than staff #3 completed CPR/First Aid training on 2-15-18 and 2-7-20. See
copy of staff CPR/First Aid training certificates. All program staff are responsible for
maintaining training requirements and are expected to respond to the alerts
generated by our training software by registering and attending training.
Employee failure to meet the training requirements of their positions will be
subject to corrective action and may not be permitted to work until the
requirements are met. Prior to a scheduled leave of absence, employees will
review training requirements coming due during the leave of absence and
employees will arrange with their supervisor to complete the training in advance
of their leave. On a monthly basis, Managers will review the Monthly Certification
Report provided by Human Resources with each of the supervisors during
supervision meetings, to discuss each employee¿s registration, schedule and
attendance at required trainings. Supervisors will follow-up with employees to
confirm registration and attendance in the appropriate courses to maintain their
requirements to continue working. All employees will be retrained in the training
requirements by 6/30/2020. A quarterly review of a sample of employee training
records will be completed by the PDs to be held in July, October, January and
April. A tool for completion of the quarterly review will be developed by
06/15/2020 and PDs will be trained in the tool by 6/30/2020. Directors will review
the outcomes of the quarterly sample reviews by the end of July, October,
January and April to determine any necessary improvements in processes and
training tracking. |
06/30/2020
| Implemented |
| 6400.52(a)(1) | Staff #3 did not complete 24 hours of annual training for training year 2018/2019. She only completed 15.75 hours of acceptable training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | A staff other than staff #3 completed 24 hours of annual training as of 4/21/20. See copy of
staff training transcript. All program staff are responsible for maintaining training
requirements and are expected to respond to the alerts generated by our training
software by registering and attending training. Employee failure to meet the
training requirements of their positions will be subject to corrective action and
may not be permitted to work until the requirements are met. Prior to a scheduled
leave of absence, employees will review training requirements coming due during
the leave of absence and employees will arrange with their supervisor to complete
the training in advance of their leave. On a monthly basis, Managers will review
the Monthly Certification Report provided by Human Resources with each of the
supervisors during supervision meetings, to discuss each employee¿s
registration, schedule and attendance at required trainings. Supervisors will
follow-up with employees to confirm registration and attendance in the
appropriate courses to maintain their requirements to continue working. All
employees will be retrained in the training requirements by 6/30/2020. A quarterly
review of a sample of employee training records will be completed by the PDs to
be held in July, October, January and April. A tool for completion of the quarterly
review will be developed by 06/15/2020 and PDs will be trained in the tool by
6/30/2020. Directors will review the outcomes of the quarterly sample reviews by
the end of July, October, January and April to determine any necessary
improvements in processes and training tracking. |
06/30/2020
| Implemented |
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