| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | individual #1 Bedroom wall on left side facing the window has a hole , three of the tiles on the Bathroom floor by the sink is cracked and one has missing pieces. | Floors, walls, ceilings and other surfaces shall be in good repair. | Individual #1 bedroom wall and bathroom tiles have been repaired on 5/21/2024 |
05/21/2024
| Implemented |
| 6400.80(b) | Backyard fence, Kitchen window and outside wall is covered with excess weed and vines. Weed and vines need to be cut and disposed of and should be kept well maintained | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 5-20-24 the program specialist contacted a Landscaping company who came out and remove all vines and weeds from backyard. |
05/20/2024
| Implemented |
| 6400.34(a) | Individual #1 last individual rights document dated 10/2022 | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Programs Specialist discussed and trained individual on his rights, a new individual rights was signed on 5/20/24. |
05/20/2024
| Implemented |
| 6400.46(b) | There was no current fire safety training for staff member #1, #2 or #3. The agency does not have a fire safety expert on staff nor a fire safety training curriculum created by an expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All Provider staff was trained by Fire safety expert trainee on areas General fire safety, ¿ Evacuation procedures, ¿Responsibilities during fire drills, ¿ The designated meeting place outside the building or within the fire safe area in the event of an actual fire, ¿ Smoking safety procedures if individuals or staff persons smoke at the home, ¿ The use of fire extinguishers, smoke detectors and fire alarms; and ¿ Notification of the local fire department as soon as possible after a fire is discovered. All staff received a fire safety certificate on 5/22/2024. |
05/22/2024
| Implemented |
| 6400.46(d) | There is no current CPR card for staff member #2 | 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. | Provider staff was trained in CPR on 5/20/24 . All staff are in compliance with 46(d) section of 6400 regulations. |
05/20/2024
| Implemented |
| 6400.50(a) | Training documents including certificates and contents of trainings need to be present with the annual training syllabus for staff member #1, #2 and #3 | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Provider staff received 6400 regulations Orientation trainings on 5/25/2024 |
05/25/2024
| Implemented |
| 6400.52(a)(1) | Staff member #1 had 14 hours of documented trainings for the 2023 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Provider staff was trained on 6400 regulations section 52a1-3, 52b1-5, 52c1-6. Signature page attached. |
05/26/2024
| Implemented |
| 6400.52(b)(1) | CEO Staff #4 did not have the required 12 hours of annual training in the 2023 training year. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | CEO was trained on 6400 regulations section 52a1-3,52b1-5, 52c1-6. Signature page attached. |
05/26/2024
| Implemented |
| 6400.162(a) | Staff #1, #2, #3 and #4 medication administration training has expired. No staff should administer medications without the correct training. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Practicum completed by Medication Certified Trainer for staff persons
on 5/22/2024 |
05/22/2024
| Implemented |