| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | There were eight cans of paint unlocked in a basement cabinet. There were three cans of paints unlocked in the garage. The paint cans noted to call poison control if accidentially ingested. The Individuals living in this home do not have the ability to safely handle poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The 8 cans of paint in an unlocked basement cabinet and the 3 cans of paint sitting unlocked in the garage were immediately removed from the premises and disposed of properly (attachments #63 and #64). All CHS staff received a memo from CHS Co-Directors, reminding them of the importance of keeping all poisons locked in the home, unless all residents in the home have been assessed as independent in handling poisons (attachment #65). To ensure compliance, Interact will further assure that all household poisons are appropriately locked as needed, by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on a CHS site 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 that all household poisons are locked as per regulations. Visits will be documented. Any/all issues found with compliance will be immediately addressed at the time of discovery by securing/locking up these items and appropriate follow up will occur with program manager and/or staff as needed. |
09/15/2015
| Implemented |
| 6400.64(a) | The window blind in Individual #3's bedroom was covered with dust. There was dust hanging from the ceiling and on the curtain rod.
The cabinet in Individual #3's bathroom had residue on the inside. The downstairs bathroom, near the dinning room, had thick brown substance in the cabinet under the sink. Individual #2's bedroom air conditioner was very dusty. | Clean and sanitary conditions shall be maintained in the home. | The window blind in Individual #3's bedroom was thoroughly cleaned (attachment #58). The entire bedroom was cleaned, including the ceiling and curtain rod (attachment #59). The cabinet in Individual #3's bathroom was cleaned of the residue that was on the inside (attachment #60). The thick brown substance that was in the cabinet under the sink in the downstairs bathroom near the dining room was removed and the cabinet was cleaned thoroughly (attachment #61). Individual #2's air conditioner was cleaned of the dust that was on it (attachment #62). A cleaning schedule was developed by program manager and posted at the site and reviewed by program manager (attachment #51) to ensure clean and sanitary conditions exist in and around the home. To ensure compliance, Interact will further assure that clean and sanitary conditions are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on a CHS site 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 cleanliness issues at the site will be immediately addressed with program manager and staff at site. |
09/18/2015
| Implemented |
| 6400.66 | The light outside the back door and the light outside the basement door were inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Both the light outside the back door and light outside the basement door were repaired and are completely functional and operate as necessary (attachments #56 and #57). To ensure compliance, 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 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. |
10/01/2015
| Implemented |
| 6400.67(a) | The last step of the basement stairs was detached and a piece of wood was sticking out causing a tripping hazard for the Individuals who reside in the home.
The kitchen cabinet had a drawer that was detached.
There were two folding chairs upstairs that had peeling paint. | Floors, walls, ceilings and other surfaces shall be in good repair. | The last step of the basement stairs was repaired and the tread was replaced so there was no longer a tripping hazard in the home (attachment #53). The kitchen cabinet drawer was repaired and replace in the cabinet and is fully functional (attachments #54 and 55). The folding chairs were immediately thrown away during the licensing inspection visit. To ensure compliance, 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 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. |
10/01/2015
| Implemented |
| 6400.73(a) | The handrail on the ramp was detached and leaning from the house. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The handrail on the ramp was reattached (attachment #52). The entire handrail was inspected to ensure that it was in good repair. To ensure compliance, 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 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. |
09/24/2015
| Implemented |
| 6400.80(b) | There was trash scattered over the backyard and the driveway. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The trash was picked up in the backyard and driveway (attachment #50). To ensure compliance, daily cleaning assignments were made by program supervisors for all sites to be completed by staff to ensure clean and sanitary conditions are maintained in the home (attachment #51 for 54th Street), to ensure clean and sanitary conditions exist in and around the home. To ensure compliance, Interact will further assure that clean and sanitary conditions are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on a CHS site 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 cleanliness issues at the site will be immediately addressed with program manager and staff at site. |
09/18/2015
| Implemented |
| 6400.101 | Individual #3's bedroom door did not open freely.
The exit door, off the kitchen area, was stuck on the carpet making it difficult for individuals to open it in an emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The door was rehung so it opens freely there was no gap between the door and the frame, so there is room for the door to open and close without a problem (attachment #48). The bottom of the exit door was shaved down to allow for free movement of the door (attachment # 49). To ensure compliance, Interact will assure that clean and sanitary conditions are maintained in the home by inspecting 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. |
09/21/2015
| Implemented |
| 6400.142(a) | Individual #5 had a dental appointment on 1/15/14 and not again until 4/22/15. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Nursing staff created spreadsheets to assist program managers in tracking appointments and their due dates. In addition, all program managers and nurses will be retrained in 11/2015, and will receive retraining every 3 months on an ongoing basis to ensure full understanding of regulations and requirements around medical appointments in an effort to ensure future compliance. Furthermore, quarterly peer review/client chart audits will be completed by program managers as assigned by CHS co-directors to ensure compliance. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
09/25/2015
| Implemented |
| 6400.164(a) | Staff #1 and #2 did not sign their full names on the medication log. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | A master signature sheet has been created and will be kept in the medication log and signed, printed, and initialed by each staff who administers medications (attachment #46). All PM's posted a memorandum at the site and in the medication log to prompt all med certified staff to sign the master signature sheet monthly, before administering meds, provided they are current in medication administration (attachment # 47). All program managers will visit their sites to ensure compliance with this regulation on a regular basis and submit documentation to CHS co-directors biweekly to document such on the CHS site review checklist. Additionally, the CHS co-directors, the assistant CHS director, and quality assurance assistant implemented a weekly alternating tour of each site to further ensure compliance to such. Any/all issues found with compliance will be immediately addressed at the time of discovery. |
10/01/2015
| Implemented |
| 6400.171 | There was an open box of hash browns stored in the freezer. There was an open box of cookies stored in the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The open box of hash browns and the open box of cookies were immediately transferred to a sealed storage bag, which was labeled and dated. Program director issued a memo to staff re: the correct storage, labeling, and dating of any open food (attachment #45). All program managers will visit their sites to ensure compliance of this regulation on a regular basis and submit documentation to CHS co-directors biweekly to document such on the CHS site review checklist. Additionally, the CHS Co-Directors, the Assistant CHS Director, and the Quality Assurance Assistant implemented a weekly alternating tour of each site to further ensure compliance to such. Any/all issues found with compliance will be immediately addressed at the time of discovery and appropriate follow up will occur with the program manager and/or staff as needed. |
09/15/2015
| Implemented |
| 6400.181(e)(7) | Individual #5's assessment, dated 10/3/14, did not include the individual's knowledge of heat sources or the ability to move away quickly. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including that the individual's knowledge of the danger of heat sources and the ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated (attachment #26). Individual #5's assessment was updated 10/2/2015 to include the missing component (attachment #44). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, program managers as assigned by CHS co-directors to ensure compliance will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/02/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #5's assessment, dated 10/3/14, did not include progress and growth in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Assessment form has been updated and revised to ensure it includes all required components per licensing requirements, including the individual's progress over the last 365 calendar days and current level in managing personal property (attachment #26). Individual #5's assessment was updated 10/12/2015 to include the missing component (attachment #44). All program managers are required to update all current assessments on their caseloads using the new form to ensure compliance with all individual assessments. Program managers will be re-trained in 11/2015, and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with assessment requirements. Furthermore, program managers as assigned by CHS co-directors to ensure compliance will complete quarterly peer review/client chart audits. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. |
10/02/2015
| Implemented |