| 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 10/7/23 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 |
| 6400.216(a) | At 11:22 AM on 11/15/23, Individual #1's records were found unsecured in a non-locking cabinet located in the apartment's living room area. | An individual's records shall be kept locked when unattended.
| On 11/17/2023 the agency purchased a file cabinet with a locking system to store binders appropriately. On 11/20/2023 the binders were placed in the file cabinet by site supervisor to be stored appropriately. The site supervisor will monitor if the binders are being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. |
11/17/2023
| 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 #1 stated that the live feed captured on the cameras is directed to an iPad that is accessible only to CEO #1 and Administrative Assistant #2. CEO #1 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, there is no side balcony attached to this apartment, 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 |
| 6400.32(r)(1) | On 11/15/23, Individual #1's bedroom door was observed with a key lock. However, Individual #1 did not have access to their own key to permit them to unlock and lock their bedroom without having to consult with staff. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | On 12/4/2023 the individual was given a key to her bedroom door. It was placed on her key ring along with her other keys by agency representative (Program Specialist) . The site supervisor will check the individual's key ring monthly to ensure that it's there and marked the status of the key on the lead checklist. The Program Specialist will view monthly check list every month and do a site quarterly check to prevent the violation from occurring again. On 12/4/2023 the CEO trained the Program Specialist and site supervisors on the individual's right to have a lock and key to their bedroom door. |
12/04/2023
| Implemented |