| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | There is no current and up-to-date financial ledger for cash-on-hand or SNAP Benefits for Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The Financial Director and program manager are responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
The agency has implemented changes to its overall financial accounting for residents. New binders have been placed at individuals' homes. The binders contain a "Money received form" and transaction forms that require staff to attach receipts and fill in descriptions of transactions and reflect a point-in-time balance.
The binder would have sections for EBT, Cash, and cards. In some cases, the individual refuses to give a receipt, so the staff must indicate on the transaction form that the individual refused to give a receipt. In other cases, the family or individual would not inform the agency of any disbursements made to them. In such cases, the transaction receipt would only reflect the transaction but no end or beginning balance.
This process was implemented on 10/14/2024 |
10/14/2024
| Implemented |
| 6400.22(d)(2) | There is no current and up-to-date financial ledger for cash-on-hand or SNAP Benefits for Individual #1. | The home shall keep an up-to-date financial and property record for each individual that includes the following:
(2) Disbursements made to or for the individual. | The Financial Director is responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received.
The agency has implemented changes to its overall financial accounting for residents. New binders have been placed at individuals' homes. The binders contain a "Money received form" and transaction forms that require staff to attach receipts and fill in descriptions of transactions and reflect a point-in-time balance.
The binder would have sections for EBT, Cash, and cards. In some cases, the individual refuses to give a receipt, so the staff must indicate on the transaction form that the individual refused to give a receipt. In other cases, the family or individual would not inform the agency of any disbursements made to them. In such cases, the transaction receipt would only reflect the transaction but no end or beginning balance.
This process was implemented on 10/14/2024 |
10/14/2024
| Implemented |
| 6400.22(e)(3) | On September 17, 2024, Individual #1 spent $15.29. There was no receipt for this purchase. | 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 Financial Director is responsible for fixing this.
The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal possessions and funds received.
This violation has been implemented on the 14th of October 2024 |
10/14/2024
| Implemented |
| 6400.64(a) | There were copious amounts of dried cat feces in litter box during the walkthrough which had a strong odor. | Clean and sanitary conditions shall be maintained in the home. | Immediate Actiion! The program manager would arrange to have the cat litter cleaned.
The agency shall ensure that all surfaces are maintained in clean and sanitary conditions.
This remediation has been completed on the day of the inspection |
09/27/2024
| Implemented |
| 6400.77(b) | There were no tweezers or scissors in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The program manager is responsible for this fix.
The agency shall ensure that a first aid kit contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors.
Leadership has prepared electronic residential checklists that are completed by different tiers of supervisors
Items for the first aid kit are included on the residential checklist. This checklist is completed every other week or multiple times a week by a different site supervisor. Management will also review and verify items in the first aid kit during Monthly site visits and spot checks.
The changes were made on 09/28/2024 and ongoing checks instituted immediately. |
10/28/2024
| Implemented |
| 6400.82(f) | There were no paper or cloth towels for use after handwashing in 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. | The program manager is responsible for making this correction.
A paper towel dispenser plus paper towel would be installed in the bathroom
The dispenser has been installed. Installation date was 10/11/2024 |
10/11/2024
| Implemented |
| 6400.171 | There were three bags of open food in the freezer including French fries and two bags of vegetables. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The program manager shall be responsible for this regulation
The agency shall ensure Food shall be protected from contamination while being stored, prepared, transported and served.
The agency discarded the 3 bags of food on the day of the inspections. On 9/26/2024, the agency issued an agency-wide communication to staff and supervisors listing proper food storage practices. On 10/09/2024, the agency also performed staff training that encompassed proper food storage practices. Visual reminders, posters, and checklists have been placed in the kitchen to reinforce proper food storage protocols. |
10/14/2024
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's most recent assessment does not accurately reflect Individual #1's progress in financial independence. It is vague and does not clearly document the support the individual needs. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist is responsible to correct this violation
The assessment would include the individuals progress over that last 365 days and current level of financial independence.
The correction was be completed by the 14th of October 2024 |
10/14/2024
| Implemented |
| 6400.32(c) | Individual #1 reported to the Department at least 15 times that they did not want to reside in the apartment they currently live in, because they are afraid of Individual #2, who resides downstairs. While the Department was present at the home, Individual #2 barged into Individual #1's apartment without knocking. Staff #1 was able to prevent Individual #2 from entering the home. Staff #1 stated that if Individual #1 saw Individual #2 they would go after Individual #2. Individual #1 does not like Individual #2 in their home. Individual #1 stated Individual #2 scares them. Individual #1 is being abused and mistreated by living in a constant state of fear. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Program specialist is responsible for this.
Agency shall ensure that an individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.
The individual is known to perseverate and repeat their wants. The individual was counseled by their behavioral consultant and assured that they are in a safe space. Individual 1 and individual 2 both have staff members and staff members have been trained to ensure no undesired contact between both individuals. Individual 2 would also be transitioning out of location within 6 months. |
10/16/2024
| Implemented |