| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On 1/5/23 at 12:13PM, upon arrival to the home, the Department and agency management staff person observed that the kitchen faucet had burst causing water to gush upward approximately 3 feet to the ceiling causing water to flow and pool throughout the first floor and basement of the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 1/4/2023 contractors and the insurance company were contacted to begin repair process. The home was placed on a waiting list with the provider Service Pro. Due to the number of homes in the area facing damage from the recent freeze, local providers did not have immediate availability. A general contractor went out to the home on 1/13/23 to mitigate the stagnant water, and assess for remodeling needs once restoration services are completed. Servpro began restoration process on 1/23/2022. The home is currently undergoing a dehumidification process and testing for mold. The home will remain vacant while the repairs are in progress. |
05/01/2023
| Implemented |
| 6400.67(b) | On 1/5/23 at 12:13PM, upon arrival to the home, the Department and agency management staff person observed that the kitchen faucet had burst causing water to gush upward approximately three feet to the ceiling causing water to flow and pool throughout the first floor and basement of the home. The amount of water flooding on the floors of the first floor and basement of the home created a slipping and falling hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 1/4/2023 contractors and the insurance company were contacted to begin repair process. The home was placed on a waiting list with the provider Service Pro. Due to the number of homes in the area facing damage from the recent freeze, local providers did not have immediate availability. A general contractor went out to the home on 1/13/23 to mitigate the stagnant water, and assess for remodeling needs once restoration services are completed. Servpro began restoration process on 1/23/2022. The home is currently undergoing a dehumidification process and testing for mold. |
05/01/2023
| Implemented |
| 6400.106 | The home had annual furnace inspections completed on 9/20/21 and then again on 10/24/22. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Program specialist created a tracking spreadsheet for furnace inspections on 01/04/2023. All homes are due at the same time this year (2023). The procedure for furnace inspection was included on this checklist. |
01/04/2023
| Implemented |
| 6400.15(b) | The agency used a Department's licensing inspection instrument modified in June 2018. The current licensing inspection summary instrument for the community homes for individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The internal policy for self-assessment was updated on 1/25/2023 to include the current Provider self-assessment tool, and previously used forms were replaced on the shared drive with the correct form on the same date. The form was forwarded via email to the Chief Executive Officer and Program Specialist on 1/6/2023 with direction that this form should be utilized moving forward per inspection. |
01/25/2023
| Implemented |
| 6400.18(a)(11) | On 1/5/23 at 12:25PM, the home required an emergency closure due to unsafe conditions due to extensive water damage throughout the home from the broken sink faucet in the kitchen for an indeterminant amount of time. As of 1/9/23, the incident has not been entered in the Enterprise Incident Management system, the Department's information management system or on a form specified by the Department. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Emergency closure.
| The agency has utilized the HCSIS help desk to ensure the submission of the emergency closure. Documentation of the submission issues as well as the submission have been retained. |
01/06/2023
| Implemented |