| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | At the time of inspection, the carpet in the staff office has numerous stains of indeterminate origin. | Clean and sanitary conditions shall be maintained in the home. | 1. 6400.64 (a) ¿ sanitation- several stains on the carpeting in the group home office. Clean and sanitary conditions shall always be maintained in the home.
a. WHO: It is the responsibility of the RSS and house supervisors to report any carpet stains to the maintenance department. This should be done via the maintenance request forms and submitted to the corporate office. Maintenance will assess the stains and try to clean them. If this is not possible it will be the responsibility of maintenance to contact a professional carpet cleaning company or replace the carpeting.
b. The carpet and stains were cleaned up by QLS Inc. maintenance.
c. The carpet was cleaned by 9/8/2020.
2. Outside of COVID-19 restrictions, QLS Inc. typically has a field manager visit all the homes on a weekly basis and provide maintenance request forms to all managers submission to the maintenance department.
3. A memo has been sent out on 9/17/2020 addressing this regulation and the role that RSS and house supervisors play while awaiting COVID-19 restrictions to be lifted.
4. No new form or plan was created due to the prior success of the policy this was simply overlooked as an effort to minimize COVID-19 exposure to the people we support.
5. Attachment #1- Memo
Attachment #7 photo of cleaned carpet |
09/08/2020
| Implemented |
| 6400.67(a) | At the time of inspection, there was an approximately 3 inch hole near the bottom of Individual #1's bedroom door. | Floors, walls, ceilings and other surfaces shall be in good repair. | 6400.67 (a)- surfaces-hole at the bottom of the bedroom door
a. WHO: RSS staff and house supervisors will be responsible for completing maintenance request forms and submitting them to the corporate office. Maintenance staff will be responsible to complete the request within a reasonable amount of time.
b. The hole in the wall at the bottom of the bedroom door was repaired
c. The hole in the wall was repaired on 9/8/2020.
2. Outside of COVID-19 restrictions, QLS Inc. typically has a field manager visit all homes weekly and provides maintenance request forms to management to fix problems within the homes.
3. A memo has been sent out on 9/17/2020 addressing this regulation and the role that RSS and House supervisors play while awaiting COVID-19 restrictions to be lifted.
4. No new form or plan was created due to the prior success of the policy this was simply overlooked as an effort to minimize COVID-19 exposure to the people we support.
5. Attachments #1- Memo
Attachment # 6- photo of fixed hole in the wall |
09/08/2020
| Implemented |
| 6400.82(f) | At the time of inspection, there was no toilet paper present in the downstairs bathroom. | 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. | 1. 6400.82 (f) - Bathrooms- toilet paper was not available in the downstairs restroom.
a. WHO: It is the responsibility of the RSS and House Supervisors to assure there is toilet paper in all of the restrooms to assure proper hygiene.
b. WHAT: An ample amount of toilet paper will be available in all the restrooms in the house.
c. WHEN and HOW: 9/1/2020- toilet paper was made available immediately in the downstairs restroom of the home.
2. Upon shift change it will be the responsibility of the RSS/house supervisor to assure all toilet paper rolls are readily available. If supplies on toilet paper is running low, it will be the responsibility of the staff on shift to let the house supervisor know to get some more prior to running out. The house supervisor will assure ample supplies of toilet paper is available for use. These will be ordered weekly on the grocery order list that is provided to the QLS Inc. corporate office by 10AM every Monday for pick up on Thursdays.
3. All house supervisors and RSS staff will be trained on 6400.82 by 9/17/2020 via Memo. This will allow everyone to understand the role they play in staying in compliance with this regulation. This is to assure proper follow through of the POC in its entirety now and in the future.
4. Cleaning check list will be updated at the houses to reflect a proper amount of supplies are available and ready for use. It will also reflect a spot check of every toilet in the home to assure there is toilet paper available for use.
5. Attachment #1- Memo
Attachment # 2- cleaning check list |
09/17/2020
| Implemented |
| 6400.174 | At the time of inspection, there were no foods in the home available to the individuals from the following food groups: fruits, vegetables, grains. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| 1. 6400.174- food groups- no fruits, vegetables, or grains were available at the house.
a. It is the job of all RSS and house supervisors to assure the proper amount of food is in the house. RSS and house supervisors will be responsible to get the grocery order to the office by 10AM every Monday due to COVID-19 and limiting exposure to grocery stores. Program specialists have the ability to make grocery runs outsides of the Monday timeframe in the case of an emergency or timeframes not being met.
b. All food groups will always be made available in all of the houses , as RSS and House supervisors will be monitoring this.
c. Memo has been sent out on 9/17/2020 addressing this issue. This is typically something the field supervisor would check for on their weekly house visits but due to limiting exposure the field supervisor is not completing home visits. Staff will fax over their shopping list to the QLS Inc. corporate office every Monday by 10AM and their groceries will be picked up on Thursdays.
2. Upon the field managers reintroduction into the houses it will be their responsibility to check the pantries and refrigerators on a weekly basis in each home to assure all food groups are made available.
3. All staff have been trained on this regulation via digital and paper copy of the attached Memo that was available on 9/17/2020.
4. A grocery checklist will be available to all of the houses by 9/17/2020 to assure foods from all of the major food groups are ordered every week.
5. Attachement #1 Memo
Attachment #5 Grocery Check list |
09/17/2020
| Implemented |
| 6400.32(d) | The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. Staff person #1 and Staff person #2 were not wearing masks during the inspection on 9/1/20. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals. | An individual shall be treated with dignity and respect. | 1. 6400.32 (d)- dignity and respect- staff were not wearing a mask when supporting people in the group homes.
a. Office manager will supply a check list to all homes to reflect COVID-19 regulations are being followed. This will include: Do you have a temperature less than 100.0 degrees, have you been out of the local area, have you been exposed to people who have tested positive for COVID-19, do you have any symptoms of COVID-19, and a reminder to wear your mask for your entire shift. RSS and House supervisor will be responsible for signing off on the check list prior to each shift to minimize the risk of exposure for the individuals we support.
b. All staff working have been reminded of the importance to wear a mask while on shift.
c. The checklist will have a reminder to wear a mask for all staff prior to their shift this will be put into place by 9/17/2020 via email and a paper copy will be picked up in the office.
2. The program specialist will check the COVID-19 check list to assure all staff are reading and signing off that they are following the regulation. This will be completed every Thursday when consumer funds are picked up. Every group home within QLS Inc. was equipped with new thermometers by 9/8/2020 to assure staff had adequate ways to check their temperature prior to working a shift in the home.
3. (HR specialist) completed a ZOOM call with all QLS Inc. staff to train on the importance of minimizing the spread of COVID-19 on 9/3/2020. On 9/11/2020, Emily sent out a PowerPoint with a quiz to all QLS Inc. staff to complete as a follow up to the training. All Staff will have completed the power point followed by the quiz by 9/30/2020
4. COVID-19 check list and the training memo that have been distributed company wide are attached to this POC.
5. Attachment #1- Memo
Attachment #4- COVID-19 check list |
09/30/2020
| Implemented |