| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The written fire drill record provided from 12/5/22 to 10/2/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | On 11/21/2023 the agency representative (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drills and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drill performed. 11/21/2023 CEO trained Program Specialist and Supervisors on updated Fire Evacuation Record. |
12/14/2023
| Implemented |
| 6400.32(h) | On 11/15/23, Ring cameras that record audio and video were observed outside the apartment unit's front door, on the side balcony, and in the living room common area. A consent form was presented by the agency and signed by the individuals. The CEO #2 stated that the live feed captured on the cameras is directed to an iPad that is accessible only to CEO #2 and Administrative Assistant #3. CEO #2 further explained that the live feed disappears from the iPad after seven days but that there is an option to save the recordings for an unlimited period of time. | An individual has the right to privacy of person and possessions. | On 12/7/2023 the audio was removed from the front door camera by disabling the audio in the system, the audio from the balcony camera was disabled, the audio was removed by disabling the audio in the system from the living room common area location. The audio will remain disabled at all times during recording. The CEO will monitor the function of the device to ensure quarterly to ensure compliance is being met. On 12/7/2023 the CEO will train the administrative assistance on the regulation surround the use of cameras in a residential settingOn 12/6/2023 the maintenance man removed all chain locks from the door. Leasing office was informed that those type of locks cannot be used in the future. On 12/07/2023 the Program Specialist check all locations to ensure locks were removed. The site supervisor will monitor locks on lead checklist monthly to ensure compliance is being met, Program Specialist will monitor lead checklist monthly and site location quarterly to ensure compliance is being met for 1 year. The CEO trained the Program Specialist on appropriate lock systems and when and how they should be used. |
12/07/2023
| Implemented |
| 6400.169(b)(2) | Direct Service Worker #1 provides care for and administers medication to Individual #1 who is diabetic, receiving insulin injections. On 8/15/23, Direct Service Worker #1 completed an online, pre-recorded diabetes training in Keppro. However, the training did not provide real-time interaction with the instructor. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | On 11/28/2023 by a certified Diabetes Care and Education Specialist. The agency representative that was responsible for coordinating trainings was the CEO. The agency was provided certificated and training signature page. The administrative assistant will track trainings through training logs, transcripts and staff profile monthly to prevent violation from occurring again. New hires will receive training from a department approved trainer prior to work with the individual. Old staff will receive department approved diabetes training annually. The CEO trained the administrative assistant training curriculum and criteria to prevent violation from occurring again. |
11/28/2023
| Implemented |