| 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: General requirements 6400.18(h)(3) through and including 6400.19(a)(5), 6400.20(c)(1) through and including 6400.22(e)(2), Individual Rights 6400.31(c) through and including 6400.32(n), 6400.32(q) through and including 6400.34(b), Staff Health 6400.151(c)(4) through and including 152(c). | 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 |
| 6400.34(a) | Individual #1 was informed of their individual rights and the process to report a rights violation on 1/1/2023, and then again on 7/28/2024. This exceeds the annual requirement. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Compliance Director, Program Specialist, and COO were trained on 6400.34 regulations in regarding informing and explaining individual rights and the process to report a rights violation upon admission to the home and annually thereafter. All individuals will be trained on Individual Rights on 1/5/2025 and annually thereafter.
An individual record check, QMP, and training verification info. was forwarded to the Department's shared folder. |
09/05/2024
| Implemented |