| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-Assessments are to be completed three to six months prior to the certificate expiring or six to nine months after the last annual inspection. This would place the self-assessments as being due from 4/18/24 through 8/30/24. The self-assessment was not completed until 9/4/24 to 9/27/24. | 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.
| The violation occurred due to a misunderstanding of the inspection notification letter.
To avoid future violations by October 31st, 2024, the Director of Programs will add the due date for the self-assessments to the calendar shared by the Director of Operations, the CEO, and the CAO. The CEO will ensure the information is entered on the calendar by 10/31/2024. |
10/31/2024
| Implemented |
| 6400.82(f) | At the time of the inspection the following items were not in the bathroom: soap, paper towels, and a waste can. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | This violation occurred because the soap and paper towels were removed by the staff because of the Individual's history of clogging the toilet, per the ISP. The Individual will occasionally move the trash can to other rooms of the house.
The Program Director will consult with the Senior Admissions & Clinical Officer to request the behavior be added to the BSP by October 31, 2024. |
10/31/2024
| Implemented |
| 6400.111(f) | The fire extinguishers were inspected on 4/6/23 and not again until 4/10/24, outside of the annual timeframe. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher service was scheduled by the company that completed the inspections. The due date was unknown by the VP of operations.
To avoid future violations, by October 31, 2024, the Director of Operations will add the due date for the fire extinguisher inspections to the calendar shared by the Director of Programs, the CEO, and the CAO.
The Director of Operations will begin scheduling the inspections 60 days before the due date. |
10/31/2024
| Implemented |