| 6500.17(c) | Self-assessment completed on 4/25/23 and 5/3/23 marked a violation for 64a -- Clean and Sanitary. There are no specific results addressing what the clean and sanitary conditions were pertaining to. Additionally, there was no written summary of corrections for this marked violation. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept for at least 1 year. | FCS Response: FCS was using the department approved self-assessment tool which does not include any space for a written summary. The agency will include page 6 and 7 from the 6500 Licensing Inspection Instrument from 7/12/2011 to the current 6500 self-assessment tool on MyODP. The supplemental pages will provide the space to provide a written summary of the correction.
Immediate Fix: The agency fixed the self-assessment tool template during inspection and provided a copy to the licensing agent. The agency also added the supplemental page that included a written summary to the home that had the violation. All self-assessments were reviewed during inspection, so we know that corrections are not needed in other homes because the agency did not find any violations in the other homes.
Providers Plan of Correction:
1. The Program Director will provide 6500.17 training clarification to the Team Supervisor and all Life Sharing Specialists no later than 5/31/23.
2. The agency corrected the self-assessment tool by adding pages 6 and 7 from the Licensing Inspection Instrument.
3. The self-assessment for was corrected on 5/10/23 using the revised template and a copy was provided to the licensing agent.
4. , Program Director, is responsible for completion of all steps of the plan of correction.
Attachments:
1. Training Summary Form for all program staff on 6500.17 and using the revised self-assessment tool. (Attachment 4)
2. Revised self-assessment tool (Attachment 5)
3. Completion of the revised self-assessment tool at (Attachment 6) |
05/31/2023
| Implemented |
| 6500.64(a) | During physical walkthrough of the home, the basement had an extreme urine odor. The smell permeated through the home and was able to be smelled from the upstairs. The basement is also the location where Individual #1's bedroom is located. Additionally, the Individual's bedroom had a very musty and damp odor. Although this citation was addressed on the agencies self-assessments, the items have not been corrected. | Clean conditions shall be maintained in all areas of the home. | FCS Response: Homes need to be clean and well-maintained both inside and outside. Clean is free of dirt, debris, marks, mold, mildew, or stains. Mold, mildew, and excessive soap scum in or around the tub is a violation. Unpleasant odors are a sanitation concern. Animal waste is considered trash and must be removed from the premises before it causes an unpleasant odor. Any sign of animal waste on any surface inside the house will be a violation. Animals that remain in a cage or tank need to have regular cleaning to avoid unpleasant odors. It is not acceptable to try to hide unpleasant odors with excessive deodorizers. Unpleasant odors need addressed with regular cleaning. The correction of an unpleasant odor must address the root cause of the odor to avoid future reoccurrence.
Immediate Fix: The individual was removed from the home. The individual can return when the violation is corrected.
Providers Plan of Correction:
1. The Life Sharing Specialist will provide 6500.64 training clarification to the primary caregiver with the violation no later than 5/12/23.
2. Program training will be provided to all homes on 6500.64 no later than 6/16/23.
3. All homes that were not already inspected by ODP will be checked for compliance with 6500.64 no later than 6/16/23.
4. A monthly inspection will be completed at until the home demonstrates compliance with 6500.64 for 1 year.
5. If a noticeable urine or mildew smell returns at any time, the individual will be removed until the caregiver can demonstrate theyre able to fix the problem and avoid future reoccurrence.
6. Copies of all completed paperwork will be sent to ODP no later than 6/23/23.
7., Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for the primary caregivers. (Attachment 1)
2. Program check for compliance with 6500.64 (Attachment 2)
3. Monthly check at on compliance with 6500.64 (Attachment 3) |
06/23/2023
| Implemented |