|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a buildup of lint behind the dryer equaling several traps full of material. | Clean and sanitary conditions shall be maintained in the home. | The area was cleaned immediately on 2/4/2020( see attachment 6). The staff were received a training that the dryer lint needs to be checked after each load of laundry was completed. If they continue to see a build up of lint they should contact their supervisor. When the Program Manager visits the site he will walk down to the basement and check the lint trap and behind the dryer.If there is an issue with lint build up, he will ensure it cleaned immediately and addressed with staff and maintenance if necessary. When random site checks are done by Co-Directors or Compliance Officer this an area that will be checked also. |
02/04/2020
| Implemented |
| 6400.67(a) | The dryer vent was leading out of a window and was not sealed around the vent allowing for an opening for animals or insects to enter the home. | Floors, walls, ceilings and other surfaces shall be in good repair. | An order for the dryer vent to be sealed was immediately sent to maintenance. The dryer vent was sealed on 2/12/2020 (see attachment #5). Program managers will visit their sites at least weekly and document such issues on CHS Review Checklist (see attachment 17), which will be submitted to co-directors biweekly. If they do identify an issue, it should be immediately sent to maintenance. In addition to the Program Managers site check, the Assistant Director and Co CHS Directors will visit the site on a rotating basis to complete site checks and identify any issues that are found. |
02/14/2020
| Implemented |
| 6400.67(b) | The counter top in the kitchen leading to the living room was loose and in danger of falling. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The counter top was stabilized and repaired on on 2 /10/2020 (see attachment 4 and 5) . It is no longer loose and in danger of falling. These items will be checked during site checks and if an issue is found, it is documented on the site Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and will do random checks to inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. The IDD Compliance Officer also completes random physical site inspections on sample of homes monthly. The visits she completes will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed |
02/10/2020
| Implemented |
| 6400.72(a) | There were tears in the kitchen screen door. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The tears on screen were repaired on 2/10/2020 (see attachment 2) . These items are checked during site checks and if an issue is found, it is documented on the site Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and will do random checks to inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. The IDD Compliance Officer also completes random physical site inspections on sample of homes monthly. The visits she completes will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
02/10/2020
| Implemented |
| 6400.72(b) | The main door in the kitchen had damaged paint and cracks throughout the surface. | Screens, windows and doors shall be in good repair. | The main door in the kitchen was painted and repaired on 2/11/2020 (see attachment 1) . These items are checked during site checks and if an issue is found, it is documented on the site Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and will do random checks to inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. The IDD Compliance Officer also completes random physical site inspections on sample of homes monthly. The visits she completes will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed |
02/11/2020
| Implemented |
| 6400.32(h) | The home had cameras in the main living areas, and no team meeting and approval of the individual, and no real policy on the use, and who has access to the cameras. | An individual has the right to privacy of person and possessions. | RCG's were released on 2/3/2020. After reviewing the evaluation and individual rights, the agency decided to remove all indoor cameras. This was completed on 2/20/2020 for all CHS homes. |
02/20/2020
| Implemented |
| 6400.165(f) | Individual #1's social emotional, and environmental plan was last updated on 6/12/18. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The individuals Social Emotional Environmental Plan was updated(attachment 8) on 2/12/2020 with current medications and the most recent information. A memo was given to the Program Manager(See attachment 8B) reminding him of the importance of updating this plan and ensuring it has the correct information. Chart audits are completed randomly by Directors, Assistant Director, and QA dept to ensure compliance. These chart audits are done semi annual to ensure the program paperwork is in compliance with the regulations. |
02/12/2020
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The ceiling beam between the kitchen and living room had scratched and peeling paint. The banister from the first to the second floors had scratched and peeling paint. | Floors, walls, ceilings and other surfaces shall be in good repair. | Interact maintenance department scraped and painted the ceiling beam between the kitchen and living room (attachment #9) as well as the banister from the first to second floor (attachment # 10). To ensure compliance that floors, walls, ceilings and other surfaces shall be in good repair, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
11/23/2016
| Implemented |
| 6400.67(b) | The transition from the kitchen floor to the hallway/living room is raised and covered with a metal strip that creates a potential tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Entire living room was carpeted to make the surfaces even and allow for a smooth transition from the living room to the kitchen (attachments #8). To ensure compliance that floors, wall, ceilings and other surfaces shall be free of hazards, Interact will assure that clean and sanitary conditions as well as furniture and equipment shall be nonhazardous, clean, and sturdy and well maintained in the home by inspecting the homes on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
12/30/2016
| Implemented |
| 6400.72(a) | Open windows in individual #2's bedroom did not have screens. Open windows in Individual #3's bedroom did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Window screen was replaced in Individual 2's bedroom and window screen was replaced in Individual #3's bedroom. Receipt from screen fabrication for windows (attachment #11). To ensure compliance that windows, including windows in doors, shall be securely screened when windows or doors are open, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed |
11/28/2016
| Implemented |
| 6400.81(k)(6) | Individual #1 did not have a mirror in their bedroom. | In bedrooms, each individual shall have the following: A mirror. | Program manager instructed Interact maintenance department to hang mirror in individual's bedroom (attachment # 12). To ensure compliance that in bedrooms, each individual shall have a mirror, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure mirrors are hung in bedrooms as required to meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
11/18/2016
| Implemented |
| 6400.101 | The outside gate at the left side of the house was off the hinges, and a railroad tie was blocking the walkway, creating a blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Interact maintenance department repaired the gate and put it back on its hinges and the railroad tie was removed from the walkway (attachment #13). To ensure compliance that stairway, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure no egresses are blocked, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
11/18/2016
| Implemented |
|
|