| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a sticky substance consistent with grease in, on and around the oven. | Clean and sanitary conditions shall be maintained in the home. | 1. On 03/11/20 the grease on around the stove was cleaned and removed. (Attachment #15)
2. Direct support professionals will be re-trained on daily and weekly responsibilities regarding the cleaning and sanitary upkeep in all homes. The training will be completed by the Team Facilitator or designee.
3. On a weekly basis, the Cluster Lead staff (newly created position) will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with the requirements of clean and sanitary conditions. (PA-QA Attachment #1)
4. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #2)
5. All Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding environmental checks. This training will be completed by the Associate Residential Directors.
6. This training will be completed by July 31, 2020. |
07/31/2020
| Implemented |
| 6400.67(a) | The toilet seat in the main bathroom was broken and coming off the toilet. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. On 03/24/20 the toilet seat in the main bathroom was replaced. (Attachment #14)
2. Direct support professionals will be re-trained on daily and weekly responsibilities regarding the cleaning, sanitary upkeep and the need to have everything in good repair; as well as reporting to the Team Facilitator when anything is broken. The training will be completed by the Team Facilitator or designee.
3. On a weekly basis, the Cluster Lead staff (newly created position) will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance that everything in the home is in good repair. (PA-QA Attachment #1)
4. The Monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #2)
5. All Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding environmental checks. This training will be completed by the Associate Residential Directors.
6. This training will be completed by July 31, 2020. |
07/31/2020
| Implemented |
| 6400.80(b) | The deck on the back of the home had floor boards that were lifting up from the surface, rails that came off with a slight pull, and warped wood in many places. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Plan of Correction:
1. The deck was repaired on 03/30/20. (Attachment #13) (The Deck was not repaired, but an order to replace was made).
2. The work to repair the deck will require an outside vendor to complete; all areas of non-compliance will be completed by July 31 2020. The Director of Maintenance will be responsible for ensuring compliance.
3. On a weekly basis, the Cluster Lead staff (newly created position) will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with environment checks under the supervision of the cluster Team Facilitator. (PA-QA Attachment #1)
4. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #2)
5. If an area of non-compliance is identified, a Maintenance request will be completed by the lead staff, Team Facilitator or designee.
6. All Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding environmental checks. This training will be completed by the Associate Residential Directors.
7. This training will be completed by July 31, 2020. |
07/31/2020
| Implemented |
| 6400.151(a) | Staff #1 did not have a physical at the time of the inspection. | 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. | 1. The biennial physical was found in HR files and placed were all training records are kept.
2. The HR department is now ensuring that the most current biennial physical is placed in the training record of all employees to maintain all records in one file.
3. Every 6 months the Director of HR or designee will run reports and ensure compliance. |
07/31/2020
| Implemented |
| 6400.181(e)(9) | Documentation of the individual #4's disability, including functional and medical limitation was not listed on the annual assessment dated 02/04/2020. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | 1. On 3/30/2020 individual¿s disability, including functional and medical limitations was documented and revised on the assessment. (Attachment #12)
2. All Program Specialist will be retrained on utilizing the Residential quarterly assessment tool which covers the area of non-compliance in this citation.
3. This training will be completed by the Associate Director who will ensure the guidelines are followed.
4. The training will be completed by July 31st 2020. |
07/31/2020
| Implemented |
| 6400.165(c) | Individual #4's medication Listerine and Ammonium Lactate 12% was not signed for on 2/16/2020. | A prescription medication shall be administered as prescribed. | 1. Individual #4 whose records were reviewed self-administers medications.
2. Individual #4 was reevaluated for medication self-administration 04/08/20 (Attachment #11)
3. All admins and DSP¿s working in the home, as well as other C.I. homes where individuals are self-administering; will be retrained on how to monitor individuals who self-medicate including how they document.
4. Senior program specialists for all the clusters will conduct the training.
5. The training on Self-Administration will be completed by 7/31/2020. |
07/31/2020
| Implemented |