| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Potentially poisonous substances, bleach and glass cleaner were found under the sink in the kitchen unlocked, accessible at the time of inspection | Poisonous materials shall be kept locked or made inaccessible to individuals. | Poisonous substances, bleach and glass cleaner were found under the sink in the kitchen unlocked, accessible at the time of inspection. A new community manager has been onboarded to ensure oversight of hazardous chemicals in the residential homes. A full site visit will be completed by the program director and the community manager on 10/15/2020 to ensure compliance has continued. Since the inspection, all hazardous supplies have been relocated to the supplies closet. The door will remain locked at all times with 24-hour supervision of the substances inside. Shared Values will ensure to maintain compliance moving forward. The community manager will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 9/16/2020. |
09/16/2020
| Implemented |
| 6400.67(a) | The Blinds were damaged and missing in individual #1's bedroom.
The blinds were damaged and missing from the living room. The first window on the left was covered with a blanket and second blind on the left was damaged | Floors, walls, ceilings and other surfaces shall be in good repair. | Shared Values will ensure all homes are in good repair. Upon inspection the blinds were damaged in the individual¿s bedroom and the living room. There was also a blanket covering one of the windows of the damaged blinds. On September 28, 2020, Shared Values will be conducting a mandatory full staff meeting for all direct support staff. During this time, all employees will revisit the process on submitting work orders for residential repairs. The facilitators will keep a sign-in sheet of all attendees. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 10/16/2020. On 10/15/2020 the program director and community mangers scheduled residential site visits to follow-up on the status of all aging repairs. The community manager will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 10/16/2020. |
10/16/2020
| Implemented |
| 6400.71 | Emergency numbers were not located near the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Shared Values will ensure emergency phone numbers are present and posted by the phones per 6400.71. The emergency contact has been updated with the nearest hospital, police department, fire department, ambulance, and position control center. Shared Values will ensure this information is continuously reviewed and updated. A new community manager has been secured for residential oversight. The community manager has revised the emergency phone numbers for all residential homes. The emergency contact numbers have been posted on-site by the phone. The information has been revised and approved by the program director. The community manager will be responsible for ongoing compliance with emergency phone numbers listed on-site. To ensure this is review the community manager will complete a provider self-assessment every three months. This will be submitted and reviewed by the program director. Completion Date 10/14/2020 |
10/14/2020
| Implemented |
| 6400.76(a) | The Oven Handle in the kitchen was damaged and missing, causing a potential hazard when in use. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection. All items must be fixed and repaired completed by 10/16/2020. On 10/15/2020 the program director and community mangers scheduled residential site visits to follow-up on the status of all aging repairs. Maintenance has requested an extension on the repairs for the kitchen handle as the items were not available for delivery. Shared Values will ensure the oven is not used until the handle has been repairs. Staff have the option to use the stove top and additional cooking appliances until the piece has arrived for the safety of the participants and the employees. Once the material arrives the stove will be repaired. A picture must be sent to management with the date of completion for documentation purposes. Expected completion date: 10/23/2020 |
10/23/2020
| Implemented |
| 6400.77(a) | The agency could not locate the first aid kit at the time of physical site inspection. | A home shall have a first aid kit. | Shared Values has re-purchased a first aid kit for all homes. The first aid kits contain the following antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. New first aid kits were purchased for all homes on 3/24/2020. Upon inspection, the first aid kit was not in the home. A replacement first aid kit was purchased same day as inspection on 9/14/2020. The inspection kits were delivered on 9/15/2020 and taken to the home the same day. First aid kits will be checked each month during the site inspection by the community manager. 9/15/2020 |
09/15/2020
| Implemented |
| 6400.82(f) | Paper towels or drying cloths were missing from the 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. | Shared Values will ensure all homes are clean, sanitary and stock with essential items. Since inspection, staff have put replacement paper towel on the rack in the bathroom. A community manager has been onboarded for the home. The community manager will be responsible for ensuring 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. This shall be monitored on a regular ongoing basis. Direct support staff will still be responsible to ensure adequate paper towel are in the bathroom at all times. 9/16/2020 |
09/16/2020
| Implemented |
| 6400.112(b) | There were No staff listed on fire drill February 2020 - May 2020 fire drills and therefore unable to determine if normal staffing conditions were present. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. |
10/28/2020
| Implemented |
| 6400.112(d) | No evacuation times were listed for the November 2019 -- May 2020 fire drills. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. |
10/28/2020
| Implemented |
| 6400.112(h) | The designated meeting place was not listed for February 2020 fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. |
10/28/2020
| Implemented |