| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 4/4/2024 indicated the following regulations were not applicable: Staff Health 6400.151(a) through and including 6400.152(c), therefore the self-assessment was not complete [Repeat violation 9/8/23, et. al and 9/21/22, et. al.]. | 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.
| All Mainstay Life Services licensed residential managers and coordinators (management staff) will complete a training on how to complete the self-assessments to meet the compliance standards. This will include what fields cannot be marked as "NA," and what needs to happen when something is found to be in violation. This training will take place by February 28th, 2025, and will be measured by the use of a sign-in sheet (who attended the training), as well as a description of the training including learning objectives (what was discussed). The reason the training will occur in February is the self-assessments are done in March, so this will be a good time to review the requirements of the self-assessments.
|
02/28/2025
| Implemented |
| 6400.67(a) | On 9/5/2024, at 11:15am in the basement of the residence, a lot of moisture was seeping through the walls causing what appeared to be mold to form in multiple areas. | Floors, walls, ceilings and other surfaces shall be in good repair. | Mold remover was sprayed on affected areas and waited for solution to work, loose paint was then scaped off, and multiple coats of foundation paint/sealer were applied to the walls/affected area. |
09/24/2024
| Implemented |
| 6400.67(b) | On 9/5/2024 at 11:13am in the basement of the residence, water was seeping from the corroded faucet fixture of the laundry basin onto the floor in front of the basin. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Mold remover was sprayed on affected areas and waited for solution to work, loose paint was then scaped off, and multiple coats of foundation paint/sealer were applied to the walls/affected area. |
09/24/2024
| Implemented |
| 6400.72(a) | Two windows did not contain screens in Individual #1's bedroom. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Mainstay Life Services purchased and installed new screens, and a whole house air conditioning unit was installed to prevent this citation from occurring again. |
09/24/2024
| Implemented |