| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certificate of compliance expires on 12/28/24. The home completed the self-assessment on 06/12/24. The self-assessment was not completed 3 to 6 months prior to the expiration of the certificate of compliance. This is the agency's first renewal inspection. | 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.
| Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument (LII) and completed the LII for all Residential Sites by October 31, 2024. |
10/02/2024
| Implemented |
| 6400.112(e) | The home's most recent fire drill during sleeping hours was conducted on 02/29/24. This exceeds the requirement for a fire drill during sleeping hours to be held at least every 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | Review current Fire Drill policy and procedures with Program Specialists and DSPs to ensure compliance is maintained. Training to occur by 10/31/2024. Our current policy and procedure states that midnight fire drills are to be completed 4 times a year to ensure compliance with this regulation. |
10/31/2024
| Implemented |
| 6400.15(b) | The agency completed the Department's self-assessment (last modified in June of 2018), which does not contain all Chapter 6400 regulations promulgated on February 03, 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | Abound Health will utilize the correct Licensing approved Licensing Inspection Instrument containing all Chapter 6400 regulations promulgated on October 2, 2019, and will complete the LII for all Residential Sites by October 31, 2024. |
10/31/2024
| Implemented |