| 6400.151(a) | Staff #6 was hired on 7/21/2025 but did not receive a physical exam prior to employment. The physical exam was completed on 7/23/2025. Staff #2 was hired on 6/19/2025 but received an initial TB test on 6/27/2025 and not prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Director of strategic development and compliance created policy to ensure that no staff start prior to compliance officer receiving all physical and TB required documentation |
01/23/2026
| Implemented |
| 6400.34(a) | Individual #1 was not informed of rights relating to regulation 33a and 33b as they are not listed on the Individual Rights signed in 2025. | 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. | Compliance officer immediately updated the document to reflect regulation 33a and 33b. Immediately:
1. All individuals will be presented the corrected/updated form for review and signature
2. This will be completed by 3/6/2026
Quality Improvement and on-going compliance:
1. The root cause was communication confusion between 6500 licensing, 6400 licensing and Faithful Homes
2. Going forward, Faithful Homes, specifically Compliance, will review the 33a, 33b and the RCG every six months to stay fresh on the correct content of the form. Once reviewed by Compliance, and any changes made to the form, the form will be sent to licensing for verification of accuracy. The verification will be requested by email so communication is clear.
3. The form and the verification by licensing will be uploaded in the Faithful Homes share drive for documentation.
4. The first form will be sent and completed by 3/6/2026. Thereafter it will be April and October of each calendar year.
Evidence of Completion
5. All documentation will be uploaded to the share drive for inspection
Hot water temperatures in bathtubs and showers may not exceed 120°F. Water Temperature was tested on 1/7/2026 by maintenance. Water temperature was turned down to under 120 degrees on 1/7/2026. Provider retrained house managers on regulation and requirement to check water temperature. Water temperature in all rooms will be tested monthly during fire drill procedure. 01/21/2026 |
01/23/2026
| Implemented |