| 6400.15(a) | The self assessment completed for this home was not dated; therefore, compliance could not be measured. | 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.
| 1. Updated Lii¿s to be reviewed with the team once available from ODP.
2. Instructions for completion will be reviewed at that time also. Instruction will be given to put name and dates at the time of inspection.
3. Team will discuss the specific sections of the Lii that they are responsible to complete prior to the pre-inspection phase in February of 2019. [Upon receipt of the current Certificate of Compliance, the CEO or designee shall develop a tracking system to ensure timely competition of the self-assessment. Prior to 3 month of the expiration date, the CEO or designee shall audit all self-assessment to ensure completion to include all required information included the date of competition to ensure timely completion. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for completing and auditing self-assessment of all of the aforementioned processes. Documentation of audits shall be kept. (AS 7/17/18)] |
07/30/2018
| Implemented |