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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | 67a There were two areas of disrepair in the bathroom.
- The area under the sink was made of particle board. This material had veneer which was peeling off and the particle board was swollen with water.
- The floor was peeling up in the area where it connected to the shower. | Floors, walls, ceilings and other surfaces shall be in good repair. | Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to areas of the bathroom to ensure good repair.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to areas of the bathroom. The owner will purchase the items needed for repair and have them installed to ensure the home is in good standing.
What will be corrected: Make sure all sites are clean and sanitary conditions, especially when it comes areas of the bathroom being in good repair in the homes to ensure the home is presented in good repair.
When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to areas of the bathroom being in good repair.
- House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the areas of the bathroom in good repair.
- House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to areas of the bathroom throughout the home, by 04/01/2024 |
04/01/2024
| Implemented |
| 6400.82(e) | 82e There was no Non-Slip Mat present in the bathtub
(Fixed at time of inspection) | Bathtubs and showers shall have a nonslip surface or mat. | Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to non-slip mats being in the bathrooms.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to non-slip mats being in the bathrooms. The owner will purchase the mats and have them installed to ensure the home is in good standing.
What will be corrected: non-slip mats being in the bathrooms
When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the non-slip mats being in the bathrooms.
- House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes non-slip mats being in the bathrooms.
- House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to non-slip mats being in the bathrooms, by 03/14/2024 |
03/14/2024
| Implemented |
| 6400.112(e) | 6400.112 (e)
No fire drills were completed during sleeping hours within the past six months. | A fire drill shall be held during sleeping hours at least every 6 months. | Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly.
What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
- Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period.
- Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 05/01/2024
-C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all sleep fire drills are done at least every six months or repeat of drill if exceeds that time period. Meetings will continue and will meet monthly before or around the 5th of the month. |
04/01/2024
| Implemented |
| 6400.142(f) | 142 (f) No current dental plan was in the record | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Plan to fix the immediate problem: Compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items; annually dental plan, in accordance to the 6400 regulations.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items, annually dental plan, in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided.
What will be corrected: That all participants are getting proper health services, especially annually dental plan.
When and How: Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individuals are getting proper health services which includes an annual dental plan.
- Dental forms are lacking a clear dental plan.
- Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individuals are getting proper health services, which includes a dental plan, by 06/01/2024.
-C.E. O will oversee Compliance Manager¿s practices via a monthly meeting to review individual¿s records. Meetings will be started 07/05/2024 and will meet monthly before or around the 5th of the month. |
06/01/2024
| Implemented |
| 6400.144 | At individual #1's dental appointment on 11/28/22, the dentist ordered a return visit in 6 months due to poor dental hygiene. Individual #1 did not return until 3/7/24. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Plan to fix the immediate problem: Compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items, dental being done on time, in accordance to the 6400 regulations.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: compliance manager will make sure individuals are getting proper health services. Especially when it comes to including the following items dental being done on time, in accordance to the 6400 regulations. original signature only and not electronically sign individual physical form in accordance to the 6400 regulations, to ensure the individual is receiving the best care that could be provided.
What will be corrected: That all participants are getting proper health services, especially dental being done on time.
When and How: Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individuals are getting proper health services.
- Some Health services weren¿t identified at time of inspections due to dental practice closing.
- Compliance manager will review the components of the 6400 and how it should be applied to the areas of non-compliance. Compliance manager will review all individual¿s files and to ensure all individuals are getting proper health services, by 05/01/2024.
-C.E. O will oversee Compliance Manager¿s practices via a monthly meeting to review individual¿s records. Meetings will be started 05/05/2024 and will meet monthly before or around the 5th of the month. |
05/01/2024
| Implemented |
| 6400.217 | The most recent Consent for release of information was dated 8/20/21. There was no current release of information documentation in the records for individual number 1. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Plan to fix the immediate problem: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper, and face sheet is filled out correctly.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will go to all the sites and would review the individuals records to ensure that all intake paper and face sheet is filled out correctly, after each new intake. Any current residence who has missing information will have the information put in and dated for the date the noncompliance was discovered.
What will be corrected: Individual¿s record did not have all components such as consent of release.
When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly.
- Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly.
- Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site after new intakes are admitted to ensure all paper has been filled out correctly, by 04/01/2024
-C.E. O will oversee that program specialist via a monthly meeting to ensure Program specialist will walk through the site after new intake is admitted to ensure all paper has been filled out correctly. Meetings will be continued and will meet monthly before or around the 5th of the month, starting 05/05/2024. |
04/01/2024
| Implemented |
| 6400.181(f) | 181(f)The was no record indicating the current assessment was sent to the ISP team | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure that progress and growth in the area of and sent to support coordinator prior to isp date.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure that they were written progress and growth in the area of functional strengths, needs and preferences of the individual, in current assessments and make sure all progress and growth in the area and sent to support coordinator prior to isp date.
What will be corrected: Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date you ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the areas and sent to support coordinator prior to isp date.
When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that assessment has progress and growth in the area and sent to support coordinator prior to isp date..
-Program specialist will create expanded progress and growth section by adding information in regard to and sent to support coordinator prior to isp date..
`Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 05/01/2024
-C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 06/05/2023 and will meet monthly before or around the 5th of the month. |
05/01/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The dryer was not maintained in a safe and sanitary manner. Upon inspection, there was a tennis ball sized amount of lint found inside the dryer lint trap. | Clean and sanitary conditions shall be maintained in the home. | Plan to fix the immediate problem: Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. The program specialist will purchase ensure that replacement items are purchased and the site is in good standing.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer.
When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer.
- program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer.
- Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer, by 04/01/2021 |
03/09/2021
| Implemented |
| 6400.66 | There were two overhead lighting fixtures within the home that were inoperable at the light switches; one in the front area of the living room and one in the rear spare bedroom. This may lead to unsafe lighting conditions within the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to having proper lighting.
When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
- Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
- Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, , especially when it comes Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents, by 04/01/2021. |
04/01/2021
| Implemented |
| 6400.80(b) | There were numerous, presumably empty, packs of Newport cigarettes strewn about both the front and back yards of the home. It is estimated that there were approximately ten such packs. As the front and back yard contained litter, the exterior of the home was not well-maintained. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept and free of items, to assure safety and to avoid accidents.
- Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the yard being kept, to assure safety and to avoid accidents.
- Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to yards being kept, to assure safety and to avoid accidents, As of 04/01/2021. |
04/01/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | There was no first aid manual in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | There was no first aid manual in the first aid kit.
Plan to fix the immediate problem: House Manager will walk through the sites and review all First aid kits to make sure all components are on site as listed in the 6400 regulations, such as the Manual.
Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual .
What will be corrected: House Manager will replace all first aid kits, at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual .
When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual .
- House Manager will walk through the sites monthly to ensure all first aid kits , at all sites, are equipped with all components are on site as listed in the 6400 regulations, such as the Manual .
- House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual, by 06/06/2019
-C.E. O will oversee that House Manger via a monthly meeting to ensure walk throughs are being done and to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual. Meetings will continue and will meet monthly before or around the 5th of the month, starting July of 2019.
A plan to prevent future occurrence: C.E.O will continue to meet with House Manager monthly. |
07/15/2019
| Implemented |
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