| 6400.15(a) | The self-assessment provided by the agency, dated 06/23/21, did not address the following regulations: 6400.191-210b3, 6400.231-245d, 6400.261a-263, or 6400.271(1)-275. | 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.
| In response to this violation of 6400.15(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the program specialists of the McGuire Memorial community home program will be trained to utilize the ¿self-assessment licensing inspection instrument¿ that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. The program specialists will be responsible for completing these self-assessments, including marking ¿NA¿ for any areas that do not apply to the house that they are assessing. Once completed, these self-assessment forms will be submitted to the Director and Assistant Director of Community Homes for their review. These self-assessments will occur within 3 to 6 months prior to the expiration date of the agency¿s current certificate of compliance. [Training on Self-Assessments, dated 3/29/22, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. |
03/09/2022
| Implemented |