| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | There was a mattress and box spring purchased on 5/17/18 for Individual #1 totaling 507.49 and then the same purchase made a few months later for 1521.66. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | On 8/20/19 the agency reimbursed the individual in the amount of $734.35 for the duplicate purchase of the mattress and box spring.
A review of Trust Records has been completed prior to 11/22/19 by the Residential Associate Directors. This record review was used to identify any additional duplicate purchases. Any duplicate purchases that were identified have been reimbursed if it is identified that it is the agency¿s responsibility.
Per Agency policy each is to maintain a ¿Trust Accountability Ledger¿. This ledger is an on-going record of purchases, including date, receipt and staff who assisted. The Associate Directors will review this ledger on a monthly basis for a period of one year. This review will be to verify proper process is followed including safeguarding client funds from making multiple purchases of the same items if the agency is responsible to replace. After a one year period the Associate Directors will review the ledger at least yearly as part of the existing Quality Review Process. Implementation of the process will begin November 2019.
On an annual basis, the Manager Corporate Compliance, or their designee, will perform a 100% review of all trust ledgers. |
11/22/2019
| Implemented |
| 6400.67(b) | There was a half inch of water covering two thirds of the basement floor. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 7/23/19 Facility Maintenance Staff cleared the area of standing water and repaired the washing machine drain pipe.
Program Specialist and RM level staff have been trained by the Director and Associate Directors on the proper use the maintenance request process in order to promptly report concerns to maintenance staff for repair. Training was completed 11/20/19. Documentation of training will be maintained in staff records.
On-going monitoring will occur through the use of the program specialist facility review process. Each assigned Program Specialist is required to complete a monthly review of each separate location. This review includes a review of the basement area of the home to assure no existing maintenance issues are present or to promptly report any that do exist. Also, the program will begin implementation of an electronic maintenance tracking system during calendar year 2020. |
11/20/2019
| Implemented |
| 6400.101 | The three sets of sliding doors in the dining room were not able to be opened | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 7/22/19 the Maintenance Supervisor completed repairs to ensure that the sliding doors could be opened and were operable.
On 7/24/19 the Residential Associate Director conducted training with Program Specialist and Maintenance regarding the need to keep all potential means of egress accessible. Documentation of training will be kept in staff files.
On-going monitoring will occur through the use of the program specialist facility review process. Each assigned Program Specialist is required to complete a monthly review of each separate location. This review includes verification that all means of egress are clear and accessible. Also, the program will begin implementation of an electronic maintenance tracking system during calendar year 2020. |
07/24/2019
| Implemented |
| 6400.181(d) | Individual #1 annual assessment dated 10/3/18 was not signed and dated by the program specialist until 11/21/18. | The program specialist shall sign and date the assessment. | On 7/29/19 the Residential Associate Director completed training with Program Specialist staff. This training addressed completion and signature of annual assessment. Documentation of training will be kept in staff files.
For a period of one year the Manager, Corporate Compliance, or their designee, will conduct quarterly reviews of 10% of residential consumers to ensure compliance with regulations. Documentation of quarterly reviews will be kept. |
07/29/2019
| Implemented |