| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | The telephone in the kitchen of home was not operable. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| Violation Status: Corrected. On September 22, 2017. A new telephone with an operable outside line has been installed in the kitchen.
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( Example, ensure , All telephones have an outside line and operable.) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/22/2017
| Implemented |
| 6400.72(a) | The two glass block windows in the office area in the basement of the home were open and did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Violation Status: Corrected. On September 21, 2017. A screen was placed inside of the basement block window. Sunrise has purchased a new window, And is awaiting its delivery. Please see Appendix #8 and Appendix 8.1 the order form.Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg. Ensure screens are located in windows and doors when opened. ) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/21/2017
| Implemented |
| 6400.72(b) | The outside of the basement door leading to the rear of the home had many areas of rust. | Screens, windows and doors shall be in good repair. | Violation Status: Corrected. On September 18, 2017. A new door has been installed. For the basement door. Please see Appendix #9 Photo. Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and follow up. ( eg. Ensure all doors are free of rust . ) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept. Responsible Party: CEO To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/18/2017
| Implemented |
| 6400.73(a) | The three outside steps near the basement of the home do not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Violation Status: Corrected. On September 24, 2017. A new handrail was installed. Near the outside steps near the basement of the home. Please see Appendix # 7 Photo.Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg. ensure handrails are installed properly inside and outside of the home exceeding two steps. ) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/24/2017
| Implemented |
| 6400.74 | The outside steps in the front and the outside steps in the rear of the home do not have a nonskid surface. The interior stairs in the basement do not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Violation Status: Corrected. On September 23, 2017. The outside front and rear steps of the home . Now has a non skid surface. The interior stairs now have non skid surface. Please see appendix # 6, 6.1 and 6.2. Photo.Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and follow up. ( example, ensuring all outside and interior steps are non skid. ) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept. Responsible Party: CEO To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/23/2017
| Implemented |
| 6400.80(a) | There is unfinished portion of the sidewalk in the front of the home and a crack in the landing of the outside step near the basement door of the home posing tripping hazards. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Violation Status: Corrected. On September 15, 2017. The unfinished portion of the sidewalk in the front. And the crack in the landing outside near the basement door has been repaired. Please see Appendix # 3 & 3.1 photo.
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg.. Unfinished walkways and no visible cracks to pose as a tripping hazard .) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/15/2017
| Implemented |
| 6400.80(b) | Underneath the addition in the back of the home there is a multitude of debris to include duct work with exposed insulation, loose bricks, cinder blocks, pieces of cement and wood, sheets of plywood, a large piece of corrugated metal and loose wiring. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Violation Status: Corrected. On September 20, 2017. Behind the home, ( underneath the addition) on the outside of the building has been cleaned and closed in. The yard is now free of any debris. Please see Appendix #5 photo.
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg..ensuring that the home has no debris and all portions of the home is intact and properly closed in.) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/20/2017
| Implemented |
| 6400.81(i) | The window facing the front of the home in the bedroom on the first floor does not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Violation Status: Corrected. On September 19 2017. New drapes was purchased. And was placed in the first floor bedroom downstairs. Please see Appendix #2
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg.. Drapes in all the residents bedrooms ) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/19/2017
| Implemented |
| 6400.81(k)(5) | The bedroom on the first floor of the home does not have a closet or wardrobe space with clothing racks and shelves. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Violation Status: Corrected. On September 17 2017. A new wardrobe closet was purchased. And is in the first floor bedroom. Please see Appendix #4 photo.
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg.. Ensure all residents rooms have a wardrobe or closet space in each bedroom.) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/17/2017
| Implemented |
| 6400.82(f) | The bathroom on the second floor of the home does not have a trash receptacle. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Violation Status: Corrected. On September 19 2017. A new trash can was purchased. And placed in the second floor bathroom. Please see Appendix #1 Photo.
Additional Measures: An additional walk trough of the home was completed on September 22 2017. Using a new LIS to ensure compliance. Please see Appendix 1.1
Process to prevent future re occurrence of this violation: Daily , The Direct Care staff will complete a daily checklist. ( Please see appendix 1.2) Documenting violations and reporting the violations and the follow up. ( eg.. Trash cans located in the bathrooms) Quarterly, The CEO will conduct a physical site inspection of the home ( Or more frequently ) When necessary to ensure compliance. Going forward, To prevent a re occurrence, The CEO will train all of our new hires ( DCS and PS) on the 6400 regulations & the LIS score sheet. Using the current violation summary report as a guide. With the emphasis on reporting non compliant issues & bringing the noted violations back into compliance in a timely manner. which is ( Priority) Documentation of the Physical site inspections and the remediation of noted violations will be kept.
Responsible Party: CEO
To be fully implemented by: This violation is corrected. And will be checked quarterly going forward. |
09/19/2017
| Implemented |