| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 10/28/24 to 10/31/24, did not provide a written summary of corrections made for the following regulation items identified as violations: 6400.46b; 6400.51a6; and 6400.151a. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Staff Person #1: 4 Feb 2025- 6400.46b- Hire date was 22 Jun 2024, so it has not been 12 months since date of hire; hence agency in COMPLIANCE with regulations.
Staff Person #2: 4 Feb 2025- 6400.46b- Hire date was 12 Oct 2024, and Incident Management training was completed 10 Oct 2024; two days prior to hire date; hence agency in COMPLIANCE with regulations.
Staff Persons #3; #4: The Self-Inspection for Code violation 6400.151, physicals were accidentally read in the reverse order. (Please SEE Supporting Documents) Hence, agency is in COMPLIANCE with regulations. |
02/04/2025
| Implemented |
| 6400.106 | The furnace inspection, completed 9/12/24, did not include a cleaning. The invoice service notes read, "I informed them that the filer needs changed." | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The CFO contacted the Heating & Air Conditioning Company to instruct them to correct the maintenance Invoices to say, "cleaning" on the documents. The annual Inspection from the heating company on 6 February 2025 documented the Maintenance Invoices to reflect, "cleaning" for all of the furnaces. (Please SEE Documents). |
02/06/2025
| Implemented |
| 6400.51(b)(4) | Direct Service Worker #1, date of hire 06/22/24, was initially trained on recognizing and reporting Incidents on 07/26/24. | The orientation must encompass the following areas: recognizing and reporting incidents. | Direct Service Worker #1, date of hire 6/22/2024 was completed 4 days after the 30-day Orientation training schedule. Orientation schedule was changed 2/5/2025 to incorporate Recognizing and Reporting Incidents through MYODP. All New Hire Direct Service Workers when hired will complete new hire orientation training and will not be permitted to begin working with Participants until orientation trainings are completed and certificate of completion is submitted to Site Operations Manager Per 55 Code Chapter 6400.51(b)(4). |
02/24/2025
| Implemented |