Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | The staff room has stained and dirty carpeting. | Clean and sanitary conditions shall be maintained in the home. | All carpets in the home have been cleaned (Attachment # 23) Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. |
08/17/2017
| Implemented |
6400.67(a) | The bedroom has missing closet doors. | Floors, walls, ceilings and other surfaces shall be in good repair. | The closet doors have been replaced (Attachment #21) Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. |
08/03/2017
| Implemented |
6400.67(b) | The laundry room has exposed wiring. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The exposed wires have been covered and secured with an electrical box (Attachment #22) Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. |
08/14/2017
| Implemented |
6400.73(b) | The porch located off the kitchen has loose and missing spindles. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The handrails and spindles have been replaced on the porch (Attachment #20). Residential managers are required to complete monthly residential safety checklists and complete work orders for any facility issues noted (Attachment #4). Associate Directors are required to complete monthly walkthroughs of each site, complete a compliance checklist, and complete a work order for facility issues noted (Attachment #5). The Executive Secretary is responsible for tracking completion of these checklists and will provide managers with a performance feedback when checklists are not completed and submitted. |
08/03/2017
| Implemented |
6400.76(a) | The living room coffee table has a scrapped surface, which is in need of refinising. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The coffee table has been removed by the facilities department (Attachment #19) Any furniture considered hazardous should be noted on monthly residential safety checklists (Attachment #4) and monthly compliance checklists (Attachment #5) so furniture can be repaired or replaced in a timely manner. |
08/03/2017
| Implemented |
6400.112(a) | There was no documentation of a fire drill in December, 2016. | An unannounced fire drill shall be held at least once a month. | The assistant trainer is responsible for tracking firedrills each month to ensure that all homes complete an unannounced drill as required. The assistant trainer will alert the Regional Director by the 20th of each month of any drills still not completed. The assistant trainer will notify the Associate Directors and Program Coordinators of drills needed to ensure drills are completed by the end of the month. The assistant trainer will send follow up emails on the 25th and last day of each month until all outstanding firedrills are turned in. All management staff were trained in fire safety and Delta¿s procedures on 10/13/2017 (Attachment #2) |
10/13/2017
| Implemented |