| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessments were dated with three different dates making it undeterminable when the self assessment was completed. | 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.
| Assistant Residential Directors will complete the self-assessment required under regulation 6400.15(a) for each COMHAR site 3 to 6 months prior to the expiration date of COMHAR¿s certificate of compliance on February 4. They will list only one date on that self-assessment, the date of completion of the self-assessment. The Lead Assistant Residential Director will monitor process and timeliness of completion. |
12/21/2016
| Implemented |
| 6400.64(a) | The skylight in the 1st floor hallway had multiple dead insects on it. | Clean and sanitary conditions shall be maintained in the home. | The skylight in the first floor hallway way cleaned by COMHAR maintenance department due to the height of the skylight. Site manager and assistant site manager will do work orders when there is a buildup of dirt and/or dead insects on the skylight. It will be monitored monthly as part of the site checks performed by the assistant site manager. Assistant site managers were trained on proper use of the monthly site checklist. |
12/21/2016
| Implemented |
| 6400.67(a) | There were four broken tiles on the floor in the laundry room | Floors, walls, ceilings and other surfaces shall be in good repair. | The broken tiles in the utility room were replaced by COMHAR¿s maintenance department. Assistant site manager will monitor site and report maintenance issues via electronic work order to maintenance department. Assistant site managers were retrained on use of monthly site checklist. |
12/21/2016
| Implemented |
| 6400.181(f) | There was not documentation Individual # 1¿s assessment dated 11/5/15 was sent to the SC. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Program Specialists were trained on Assessments and disseminating them on time, within 30 days of an ISP meeting on 10/25/2016 by Day Director and again on 11/8/2016 and 12/15/2016 by Clinical Coordinator. There will be ongoing monitoring by the Clinical Coordinator in order to review with the Program Specialist that the documentation is complete and meets licensure requirements. |
12/21/2016
| Implemented |
| 6400.185(b) | The individual support plan for individual 1 did not contain documentation that indicated the plan was implemented as written. The plan indicated that individual # 1 would have 5 community contacts per month however he did not have 5 contacts in July, June, April and January of 2016. | The ISP shall be implemented as written. | Site Manager monitored that individual#1 completed his goal of having 5 community outings each month and documented the outings in the September, October and November 2016 monthly reports. The Program Specialists were trained on checking ISP outcomes on 9/13/2016 by the Clinical Coordinator. Leonard¿s program specialist will monitor his monthly reports on an ongoing basis to see that his goal criteria are being met. |
12/21/2016
| Implemented |