| 6400.15(a) | The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. On the self-assessment provided, with a completion date of "August 2024," the following regulations were left blank: Individual rights 6400.32(q) through and including 6400.34(b), Staffing 6400.50(b) through and including 6400.52(c)(6). | 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.
| To correct the violation, LRS will implement a physical site inspection checklist that the team leads for each location will complete monthly to maintain all sites in compliance. LRS will also begin the self-assessment on March 1st, six months before the certification of the compliance expiration date. The self-assessment must be completed in its entirety and forwarded to Mr. Andrew Wimbish, President, by May 31, 4 months before the certification of the compliance expiration date. The self-assessment will include the beginning and end dates on which the assessment was conducted. The completed self-assessments with supporting documentation will be maintained in the LRS shared drive. |
09/13/2024
| Implemented |