| 6400.15(a) | The home's self-assessment, completed on 4/12/2024, indicated the following regulations were not applicable: Plan Development/ Process/ Content 6400.182(a) through and including 6400.209, 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 |