| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment of the home, completed date 4/12/24, indicates violations for 6400.14(a)-(c); however, there was no written summary of corrections made. | 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.
| 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 |
| 6400.151(a) | Direct Services Worker (DSW) #1's most recent physical examination was completed on 3/7/23. DSW #1's previous physical examination was not provided, therefore compliance with the every 2-years requirement could not be measured. | 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. | It is now practice that, before a staff member switches from an administrative role to a program operations role, Human Resources will conduct a review of their personnel file for compliance purposes. Any areas of concern identified, will be addressed prior to the transition. This new practice was instituted as soon as the citation was discovered during licensing. This will ensure that physical examinations are in compliance. |
09/05/2024
| Implemented |
| 6400.151(c)(2) | Direct Services Worker (DSW) #1's most recent tuberculin evaluation was completed on 3/2/23. DSW #1's previous tuberculin evaluation was not provided, therefore compliance with the every 2-years requirement could not be measured. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | It is now practice that, before a staff member switches from an administrative role to a program operations role, Human Resources will conduct a review of their personnel file for compliance purposes. Any areas of concern identified, will be addressed prior to the transition. This new practice was instituted as soon as the citation was discovered during licensing. This will ensure that physical examinations and TB tests are in compliance. |
09/05/2024
| Implemented |