| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | On 10/29/2024, the agency's self-assessment of the home did not contain an end/completion date of the assessment; therefore, compliance could not be measured. Additionally, the following 6400 regulations were not addressed and left blank: 11 under General Requirements; 31e under Individual Rights; 50b, 51a1, 51a2, 51a3, 51a4, 51a5, 51a6 under Staffing; 63b, 67c, 69c, 75a, 81g under Physical Site; 106, 109b, 111f, 113a under Fire Safety; 142e, 142f, 142g, 142h, 143a, 143b, 144, 145(1) under Individuals Health; 151a, 151b, 151c1, 151c2, 151c3, 151c4, 152a, 152b, 152c under Staff Health; 166a10 through and including 169c2 under Medications; 181b through and including 181e10 and 181e12 through and including 181f under Assessments; 182a through and including 183a7 and 184(8) through and including 195c1 under Plan Development/Process/Content; 189b through and including 190c under Day Services/Recreational and Social Activities; 194c through and including 207(2) under Restrictive Procedures; 211b4, 212, 212b, and 213(2) through and including 217 under Individual Records; 240a through and including 241a, 242 through and including 245d under Nine or More Individuals; 251a and 251b under Emergency Placement; 261a through and including 263 under Respite Care; 271(1) through and including 275 under Semi-Independent Living. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Director of Programs will complete the self - assessment on the ODP approved agency form only. The self - assessment will be completed between June and September which is 3-6 months prior to the expiration of the certificate of compliance. Areas of non - compliance will be addressed by the Director of Programs. |
11/01/2024
| Implemented |
| 6400.64(a) | On 10/30/24 at 10:27AM, the garage walls contained a dark colored substance around the perimeter appearing to be mold-like. | Clean and sanitary conditions shall be maintained in the home. | On 11/14/2024 a mold mitigation team cleaned and treated the mold in the garage. |
11/01/2024
| Implemented |
| 6400.68(a) | On 10/30/24 at 10:36AM, the hot water temperature at the sink in the second-floor bathroom measured 83.6 degrees Fahrenheit. | A home shall have hot and cold running water under pressure. | DSP staff were trained 11/8/24 on the water temperature forms. Overnight DSP staff will complete daily water temperature logs. Water temperature that exceeds 120 degrees Fahrenheit or below 110 degrees Fahrenheit DSP staff will notify the Program Specialist to submit an emergency maintenance request. The program specialist will complete the emergency maintenance request form to address water temperature. The maintenance request will be completed by the agency repair contractor. |
11/08/2024
| Implemented |
| 6400.72(a) | On 10/30/24 at 10:32AM, the second-floor bathroom window did not contain a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The director of operations scheduled with the maintenance provider to install longer plexiglass over the window in the bathroom. The window currently has a plexiglass covering however it was not long enough and the window was able to be opened. The bathroom has an exhaust fan installed - the window does not need to be used for ventilation. |
11/25/2024
| Implemented |
| 6400.101 | On 10/30/24 at 10:26AM, the basement door leading from the garage contained a dead bolt lock and also a thumb turn lock. [Repeat violation 11/14/23, et. al.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door leading to the basement garage will have the locked removed no later than 11/25/2024 .A maintenance request has been submitted for the lock removal on 11/1/24. |
11/25/2024
| Implemented |
| 6400.141(c)(14) | Individual #1's annual physical examination, completed on 9/27/24, did not address medical information pertinent to diagnosis. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program Specialist will ensure that the individual form is completed in its entirety prior to uploading forms to the agency shared drive. Any forms that are not completed in its entirety will be returned to the physician for review. This will be the responsibility of the Program Specialist to ensure compliance |
11/01/2024
| Implemented |
| 6400.181(e)(12) | Individual #1's annual assessment, completed on 3/15/24, did not include recommendations for specific areas of training, programming, and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist was retrained on 11/4/24 on the components of the annual assessment. The components of the assessments were reviewed and programming. The Program Specialist will complete all components of the assessment and the final review will be completed by the director of programs. The Director of Programs will review the assessment prior to being sent to the team. |
11/04/2024
| Implemented |
| 6400.182(c) | Individual #1's annual assessment, completed on 3/15/24, indicates that verbal prompts are required for evacuation during a fire. The individual plan that was last updated on 9/19/24 reads, "[Individual #1] recognizes the fire alarm and is able to evacuate [their] home to the designated meeting place independently." | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist will ensure that the assessment drives the ISP. The program specialist will ensure that the assessment information is accurately captured in the individual ISP. The Program Specialist will email the Supports Coordinator to update the ISP accordingly. The program specialist was trained on 11/1/24 by the Director of Programs - to ensure the understanding that the assessment drives the ISP. The Program Specialist was re-trained on the components of the ISP and assessment. |
11/25/2024
| Implemented |
| 6400.192 | On 10/30/24 at a 10:18AM, the kitchen knife was being locked in the staff office. Currently the restrictive procedure being implemented for the home does not contain knives or sharp objects. Individual #1's individual plan that was last updated on 10/29/24 reads, "[Individual #1] does not have access to sharp knives due to past behavioral concerns." | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | The restrictive procedure was updated to reflect the need to keep all sharps locked due to past behavioral concerns 10/31/2024. |
10/31/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not contain the date of admission. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Program Specialist was retrained on the individual face sheet. The Program Specialist will complete all components of the face sheet during the admissions process. The Director of Programs will complete a final review of all intake admissions forms to ensure compliance. |
11/01/2024
| Implemented |