| 6400.15(a) | The self-assessment for the home completed on 11/9/22 did not assess compliance with the following regulations: 6400.162a, 6400.166a6 -- 6400.166a14, and 6400.213(3) -- 6400.213(5). | 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.
| Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. |
10/01/2023
| Implemented |
| 6400.15(c) | (Repeated Violation -- 7/11/22) The self-assessment for the home completed on 11/9/22 did not include a written summary of corrections for the following violations: 6400.46b, 6400.51b5, 6400.141c12, and 6400.151c2. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. |
10/01/2023
| Implemented |