| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Annual Self Inspection for this location was not completed in the correct timeframe. | 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. | The annual self-inspection was not completed within the time frame outlined in the 6400.15(a) regulations. The Operations Director will be retrained by the COO by 11/11/2024, on the proper timeframe to complete annual self-inspections. Training is attachment #10. |
11/11/2024
| Implemented |
| 6400.66 | At the time of the 10/22/24 inspection, there was no light illuminating the rear deck entrance. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Maintenance was contacted and a light was added on 10/28/24, to the exterior wall, by the deck, at the back of the home. A picture was taken of the light and will be included with the receipt as attachment #1 |
11/11/2024
| Implemented |
| 6400.112(c) | The 04/21/24 fire drill log does not indicate that all the smoke detectors were checked and operating correctly during the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | All fire drills are currently uploaded into SharePoint and reviewed by the Quality Assurance Director or the Quality Assurance Associate. As an added level of over site the Operations Director will be contacted if errors are not corrected, prior to Quality Assurance uploading it into SharePoint. Program Managers will be trained on 6400.112(c) and 112(h) by the Operations Director on 11/11/2024. |
11/11/2024
| Implemented |
| 6400.112(h) | The 04/21/24 fire drill states that not all the Individuals participating in the drill successfully evacuated to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | All fire drills are currently uploaded into SharePoint and reviewed by the Quality Assurance Director or the Quality Assurance Associate. As an added level of over site the Operations Director will be contacted to address any errors prior to Quality Assurance uploading it into SharePoint. Program Managers will be trained on 6400.112(c) and 112(h) by the Operations Director on 11/11/2024. |
11/11/2024
| Implemented |
| 6400.151(b) | Staff #6's current physical is not dated by the signing physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | When a new hire or current staff submit their physical and TB Test, the Administrative Assistant will log the dates of completion in ADP (Payroll and HR Software). Upon completion, the corresponding HR Specialist will review the documents to ensure all the information is accurate and correct according to the 6400 regulations. If there are any concerns, the HR Specialist will reach out to the staff member to correct any errors with the treating physician. If the person does not have a complete and accurate physical and TB Test by the due date, they must be removed from working directly with the people receiving services. |
11/06/2024
| Implemented |