| 6400.15(a) | The self-assessment, dated 06/23/21, was not complete. The following sections of the self-assessment were left blank: General Requirements 6400.11 through 6400.25(d); Individual Rights 6400.31(a) through 6400.34(b); Staffing 6400.42 through 6400.52(c)(6); Individual Health 6400.141(a) through 6400.145(3); Staff Health 6400.151(a) through 6400.152(c); Medications 6400.161(a) through 6400.169(d); Nutrition 6400.171 through 6400.176; Assessments 6400.181(a) through 6400.181(f); Plan Development/Process/Content 6400.182(a) through 6400.209; Home Services 6400.188(a) through 6400.188(d); Day Services/Recreational and Social Services 6400.189(a) through 6400.190(c); Restrictive Procedures 6400.191 through 6400.208(f); and Individual Records 6400.211(a) through 6400.217. | 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.
| In response to this violation of 6400.15(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the program specialists of the McGuire Memorial community home program will be trained to utilize the ¿self-assessment licensing inspection instrument¿ that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. The program specialists will be responsible for completing these self-assessments, including marking ¿NA¿ for any areas that do not apply to the house that they are assessing. Once completed, these self-assessment forms will be submitted to the Director and Assistant Director of Community Homes for their review. These self-assessments will occur within 3 to 6 months prior to the expiration date of the agency¿s current certificate of compliance. [Training on Self-Assessments, dated 3/29/22, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. |
03/09/2022
| Implemented |