| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Mold was found along the edge of the bath tub in the bathroom.
A brownish stain, consistent with rust, was found in the cabinet below the toilet sink in the bathroom. There were also used tissue papers left in the same cabinet in the bathroom
| Clean and sanitary conditions shall be maintained in the home. | Property owner was notified immediately with all site issues of concern to have them rectify issues.
On a weekly basis, Site Supervisors will use the Site Safety Check List concern sheet and document all areas of non-compliance issues.
The Safety Check List will be completed and is brought to weekly meeting with Program Director. Program Director will note all areas of concern and submit the concerns to the Program Administrator. The Program Director will contact the property owners or manager for corrective actions. Program Director will ensure all concerns are addressed/corrected as soon as possible and inform Program Administrator of completion.
Program Director will provide the following training to Site Supervisors
1. To complete the Site Safety Check List and
2. To bring Check list to weekly meeting
3. To bring immediate concerns to the Program Director as needed
4. Outcome when protocol is not followed. |
09/16/2016
| Implemented |
| 6400.67(a) | There was peeling formica on the front and side of the toilet and sink located in the bathroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Property owner was notified immediately with all site issues of concern to have them rectify issues.
On a weekly basis, Site Supervisors will use the Site Safety Check List concern sheet and document all areas of non-compliance issues.
The Safety Check List will be completed and is brought to weekly meeting with Program Director. Program Director will note all areas of concern and submit the concerns to the Program Administrator. The Program Director will contact the property owners or manager for corrective actions. Program Director will ensure all concerns are addressed/corrected as soon as possible and inform Program Administrator of completion.
Program Director will provide the following training to Site Supervisors
1. To complete the Site Safety Check List and
2. To bring Check list to weekly meeting
3. To bring immediate concerns to the Program Director as needed
4. Outcome when protocol is not followed. |
09/16/2016
| Implemented |
| 6400.142(a) | Individual #1's current dental examination was completed on 3/22/16 and the previous dental examination was completed on 2/24/15. | 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. | The Medical Coordinator will utilize a tickler to include all appointments that are due and the ones that have been completed. The Program Director review the tickler on a weekly basis to ensure appointments are being completed in a timely manner. Program Director will meet with Site Supervisors weekly to review all appointments/cancellations and paperwork.
The Program Director will provide the following training to Site Supervisors, Program Coordinator and Medical Coordinator:
1. Regulations
2. Appointment protocol
3. Appointment Tickler
4. Outcome when protocol is not followed. |
08/31/2016
| Implemented |