| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | On 9/7/23 at 11:00AM, a trash receptacle measuring 27 inches in height was found in the garage filled to the top with garbage and no lid. | Trash receptacles over 18 inches high shall have lids. | The garbage can in question was replaced with a garbage can with a lid. All house staff and supervisors will be retrained on the requirement that trash receptacles over 18 inches in height need lids. This will be done at upcoming staff meetings. [Additional information received from the agency via email on 10/4/23: House staff and supervisors will be trained on the requirement that trash receptacles over 18-inches high require a lid will occur on or about 10/10/23. Home Safety Checklists will be completed by program managers on a quarterly basis and reviewed by program coordinators. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/07/2023
| Implemented |
| 6400.101 | On 9/7/23 at 10:59AM, the basement egress was obstructed by a sliding chain door lock. At 11:02AM, the first-floor side egress was obstructed by a swing bar door lock. At 11:03AM, the first-floor front egress was obstructed by a swing bar door lock and a sliding deadbolt. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| All locks in question were removed. [Additional information received from the agency via email on 10/4/23: Maintenance department staff will be trained on the types of locks that can be utilized in licensed service settings on or about 10/6/23. Direct care staff will be trained on obstructed egresses during "November staff meetings." Obstructed egress checks have been added to the Home Safety Checklist, to be completed quarterly by the program manager and reviewed by the program coordinator. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/07/2023
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained their individual rights explained on 01/12/22, and then again on 02/07/23. This exceeds the annual requirement. [Repeat violation 09/21/22 et. al] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Mainstay will reinstate a process of distributing individual rights information to residential supervisors at the beginning of each calendar year so that the rights will be explained to all individuals receiving services on an annual basis. [Additional information received from the agency via email on 10/4/23: Training related to informing and explaining Individual Rights to individuals on an annual basis is scheduled to occur on or about 10/10/23. DPOC by HDKP, HSLS on 11/1/23]. |
09/19/2023
| Implemented |
| 6400.46(b) | Direct Service Worker #1 completed fire safety training on 4/26/2022 and then again on 5/28/2023. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Mainstay has hired a training manager who will be responsible for tracking training for staff to ensure compliance with training requirements. [Additional information received from the agency via email on 10/4/23: The hired Training Manager is anticipated to start on 10/2/23. The Training Manager will be trained on orientation and annual training requirements for all staff on or about 10/3/23. Administrative and supervisory staff will be trained on orientation and annual training requirements for staff on or about 10/10/23. DPOC by HDKP, HSLS, on 11/1/23]. |
09/26/2023
| Implemented |