| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed between 1/29/23 and 1/30/23, the agency license expires 8/27/2023. | 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.
| LIIs are scheduled to be completed beginning on the week of 3/20/23. Once completed, the LIIs will be turned into the Director of Compliance for review and to maintain. |
05/27/2023
| Implemented |
| 6400.101 | On 3/1/23 at 12:30 PM, the basement door leading into the garage was observed equipped with a deadbolt and doorknob lock facing the garage side where a key would be necessary to unlock it. The garage did not have a man door but only vertical-opening automatic garage doors from which to exit the building. Aat 12:33 PM, a 1" x 1" wooden spindle was found engaged in the track of the sliding glass door, which serves as the only outside exit from the basement. [Repeated Violation---3/29/22.] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The kick lock was removed on 3/10/23. All Supervisors were instructed to confirm that there were no blocked egresses in their sites by 3/17/23. The Site Supervisors were instructed to confirm that all doors and exits are clear by 3/24/23. The deadbolt was removed on 3/17/23. The doorknob with a keylock will be replaced no later than 3/24/23. |
03/10/2023
| Implemented |
| 6400.104 | The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Letters to the local Fire Department were updated to include bedroom locations and mailed on 3/20/23. All supervisors were instructed to review their letters and confirm that they include the location of bedrooms and are accurate with the needs of the individuals no later than 3/17/23. |
03/20/2023
| Implemented |
| 6400.151(a) | Direct Service Worker #1 had physical examinations completed on 7/10/20 and subsequently on 1/3/23. | 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. | Direct Service Worker #1 last physical exam was completed on 1/3/2023, the next physical exam will be completed prior to 1/2/2025. |
03/16/2023
| Implemented |
| 6400.151(c)(2) | Direct Service Worker #1 had tuberculin skin tests via Mantoux method read with negative results on 7/10/20 and subsequently on 12/23/22. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Direct Service Worker #1 last tuberculin skin test via Mantoux method was read with negative results on 12/23/22, the next tuberculin skin test will be completed prior to 12/22/2024. |
03/16/2023
| Implemented |
| 6400.18(i) | EIM Incident # 9106491 for Behavioral Health Crisis has a discovery date of 10/16/22 with a final report due date of 11/15/22. No extensions have been requested, and no final report has been submitted. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | All open incidents that were near or over 30 days were reviewed and had an extension filed or were finalized on 3/17/23. On Monday mornings, the Director of Risk Management will provide a report of all open incidents to Residential Management. The incidents will be discussed every Friday morning with the Risk Dir and Residential Management. Quarterly, the Risk Manager will meet with the interagency Risk Management team to discuss incidents and trends. Documentation of all provided reports and meetings will be kept by the assisgned manager. |
03/17/2023
| Implemented |
| 6400.46(b) | Temporary Direct Service Worker #2's date-of-hire is 8/9/22 did not have fire safety training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The Temp DSP has been contacted and will complete required site specific trainings no later than 3/31/23. |
03/31/2023
| Implemented |
| 6400.46(d) | Direct Service Worker #1 had first aid, Heimlich techniques, and cardio-pulmonary resuscitation 9/26/18 and then 2/8/22. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Direct service worker #1 most recent certification in first aid, Heimlich techniques and cardio-pulmonary resuscitation was on 2/8/2022. This person will be required to be recertified in all three areas prior to 2/7/2024. |
03/20/2023
| Implemented |
| 6400.51(a)(3) | Temporary Direct Service Worker #2, date of hire 8/9/2022 did not have record of having completed orientation training. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | The Temp DSP has been contacted and will complete required site specific trainings no later than 3/31/23. |
03/31/2023
| Implemented |
| 6400.52(c)(5) | Direct Service Worker #1's 2022 annual training did not include review of Individual #1's restrictive procedure plan for whom they provide care. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | An updated training record was completed for the DSPs and Program Specialists to track their ISP trainings in addition to behavior support plans, crisis plans, and any other client specific trainings on 3/17/23. |
03/17/2023
| Implemented |