Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | The Range Hood over the stove was not clean and sanitary. | Clean and sanitary conditions shall be maintained in the home. | The grease has been cleaned from the stove hood 10/1/19.
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
6400.66 | There was no light in individual #2's bedroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light switch in Individual #2's room has been fixed 9/26/19. (Attachment #28)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
6400.67(a) | The kitchen cabinets were missing knobs. | Floors, walls, ceilings and other surfaces shall be in good repair. | The knob on the kitchen cabinet has been replaced 9/24/19. (Attachment #29)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
6400.67(b) | There was Lint build-up found in the dryer.
The Inspector was unable to access the homes attic based on safety. The Ladder was not in good repair. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The flexible hose on the dryer vent has been cleaned 10/22/19. (Attachment #30) The attic access has been moved to the kitchen on 10/11/19 (Attachment #31)
A bi-monthly site inspection process and form will be developed and occur. Going forward, when a facility related issue is determined by the site inspection completed by the Regional Director and the Facilities Director or their designee, staff will complete a Facility Repair work ticket. The Facility Director will provide an estimated repair date based on the severity of the needed repair and ensure repairs are completed within at least 1 month unless noted why the time frame needs to be extended. |
02/01/2020
| Implemented |
6400.181(e)(14) | Individual #1's assessments completed on 3/11/19 and 3/11/18 have inconsistencies. Under the likes section, it states individual #1 likes to swim, however under the water skills section it states he doesn't like to swim. Also, the Knowledge of water safety is not fully addressed in the assessment. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Assessment template redone on 10/1/19 to update and amend to include clear likes and water skills. (Attachment # 3)
Individual # 1's assessment has been redone on the new template and sent to his team. (Attachment #32)
Going forward all assessments will be completed on the new template by the Program Specialists. |
12/10/2019
| Implemented |