Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.15(a) | The self-assessment for the home completed on 11/8/22 did not assess compliance with 6400.51b5. | 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.
| Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. |
10/01/2023
| Implemented |
6400.15(c) | (Repeated Violation - 7/11/22) The self-assessment for the home completed on 11/8/22 did not include a written summary of corrections for the following violations: 6400.21a, 6400.21c, 6400.21d, 6400.143a, and 6400.151c2. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. |
10/01/2023
| Implemented |
6400.67(a) | The shower in the hallway bathroom was missing caulk or a protective sealant between the top and bottom sections of the shower/bathtub combination. The area where the two pieces meet had a black line of unknown substances in the crevice. | Floors, walls, ceilings and other surfaces shall be in good repair. | Residential homes tub was caulked on 8/4/23. |
10/01/2023
| Implemented |