| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 11/15/23, a receipt dated 9/15/23 in the amount of $10.00 was observed and documented as an expense on Individual #1's financial ledger as "parking for SSI office," verifying that they had been required to pay for staff parking in the agency vehicle. | Individual funds and property shall be used for the individual's benefit. | The agency never collected any funds from the individual or rep-payee and never paid any room or board. The agency provided all necessities and recreational needs for the individual. The funds were never identified as the individual's they were placed in the home to use as needed. On 12/11/2023 the individual was reimbursed the $10 dollars for parking. The agency representative that was responsible for the change was Joanne Walker (Program Specialist). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collect and not just room (Agency prior to 12/1/23 only collected room). The agency representative that was responsible for the change was supervisor Cynthia Adams (supervisor). On 12/01/2023 the CEO updated the agency policy to reflect that when funds are being distributed directly to the individual hands that the person distributing the funds along with the individual will sign that the individual is %100 responsible for all funds placed in their hands. In addition, all expenses over $15, in a case where the funds are not distributed directly to the individual's hands, there should always be an itemized receipt. The agency representative Joanne Walker will monitor the individual's funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/10/2023
| Implemented |
| 6400.22(e)(2) | On 11/15/23, staff interviews revealed that $40.00 was disbursed directly to Individual #1 on 9/30/23. This disbursement was documented on Individual #1's financial ledger as "Kennywood." However, there was no receipt provided to verify that the funds had been disbursed directly to Individual #1. Additionally, documentation of this $40-disburement as "Kennywood," on individual #1's financial ledger does not provide enough information to determine if $40 was disbursed directly to Individual #1 on 9/30/23. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | The agency never collected room or board from the individual. The agency provided all necessities and recreational needs for the individual. The funds were never identified as the individual's they were placed in the home to use as needed On 12/01/2023 the agency updated and signed a new room board contract along the with individual to reflect room and board being collect and not just room (Prior to 12/1/2023 the agency only collected room). The agency representative that was responsible for the change was supervisor (supervisor). On 12/01/2023 the CEO updated the agency policy to reflect that when funds are being distributed directly to the individual hands that the person distributing the funds along with the individual will sign that the individual is %100 responsible for all funds placed their hands. In addition, all expenses over $15, in a case where the funds are not distributed directly to the individual's hands, there should always be an itemized receipt. The agency representative Joanne Walker will monitor the individual's funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/01/2023
| Implemented |
| 6400.22(e)(3) | On 11/15/23, Individual #1's financial ledger included the following handwritten receipts: $50.00 for "ID" on 8/21/23; $23.00 for "coloring color wonders" on 9/13/23, and $54.95 for "Walmart laundry card" on 9/25/23. No actual, itemized receipts were provided verifying what was purchased for the above transactions that exceed $15. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The agency never collected room or board from the individual. The agency provided all necessities and recreational needs for the individual. The funds were never identified as the individual's they were placed in the home to use as needed On 12/01/2023 the agency updated and signed a new room board contract along the with individual to reflect room and board being collect and not just room (Prior to 12/1/2023 the agency only collected room). The agency representative that was responsible for the change was supervisor (supervisor). On 12/01/2023 the CEO updated the agency policy to reflect that when funds are being distributed directly to the individual hands that the person distributing the funds along with the individual will sign that the individual is %100 responsible for all funds placed their hands. In addition, all expenses over $15, in a case where the funds are not distributed directly to the individual's hands, there should always be an itemized receipt. The agency representative will monitor the individual's funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/01/2023
| Implemented |
| 6400.67(a) | At 10:22 AM on 11/15/23, there was observed a one-inch thick ring of rust and peeling paint underneath the turntable inside the microwave located in the kitchen of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 11/17/2023 the agency purchased a new microwave to replace the old microwave. On 11/18/2023 the microwave was delivered to the home and placed in the appropriate place for use. The site supervisors will monitor all appliance conditions and function monthly on the lead checklist to ensure compliance. The Program Specialist will monitor all lead checklist monthly and site locations quarterly to ensure compliance.
The CEO trained the trained the Program Specialist and the Supervisors on Floors, walls, ceilings and other surfaces shall be in good repair and how it will be tracked to prevent violation from occurring again. |
11/18/2023
| Implemented |
| 6400.101 | On 11/15/23, there was a sliding chain latch-lock found on the front exit door of the home, posing a possible entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 12/6/2023 the maintenance man removed all chain locks from the door. Leasing office was informed that those type of locks cannot be used in the future. On 12/07/2023 the Program Specialist check all locations to ensure locks were removed. The site supervisor will monitor locks on lead checklist monthly to ensure compliance is being met, Program Specialist will monitor lead checklist monthly and site location quarterly to ensure compliance is being met for 1 year. The CEO trained the Program Specialist on appropriate lock systems and when and how they should be used. |
12/07/2023
| Implemented |
| 6400.112(c) | The written fire drill record provided from 12/20/22 to 10/22/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered. | 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. | On 11/21/2023 the agency representative Gail Tooks (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drills and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drill performed. 11/21/2023 CEO trained Program Specialist and Supervisors on updated Fire Evacuation Record. |
11/21/2023
| Implemented |
| 6400.216(a) | At 10:25 AM on 11/15/23, binders containing personal records and documents related to Individual #1 and Individual #2, including but not limited to their assessment, individual plan, physical and dental examinations, were discovered on the floor of the dining room. | An individual's records shall be kept locked when unattended.
| On 11/17/2023 the agency purchased a file cabinet with a locking system to store binders appropriately. On 11/20/2023 the binders were placed in the file cabinet by site supervisor to be stored appropriately. The site supervisor will monitor if the binders are being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. |
11/20/2023
| Implemented |