| 6400.15(a) | The agency's certificate of compliance expires on 8/10/16. The agency completed a self-assessment of the home on 6/3/16. | 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.
| Upon receipt of the certificate of compliance, Program Director will develop a timeline of tasks to be completed and share with all program staff via manager¿s and assistant manager¿s meetings and email alerts. Program Director will set deadlines for Program Specialists, medical personnel and HR to complete pre-inspection checklists (LICENSING INSPECTION INSTRUMENT SCORESHEET.) The Program Director will track completion of Pre-Inspection checklists and will file in PD office so they will be available to inspectors when they arrive. All Pre Inspection checklists will be completed 3-6 months prior to expiration listed on certificate of compliance. Program Director will assign Program Specialists group homes to inspect. [Immediately, the CEO will review the most recent Certificate of Compliance to determine the date the current license expires an develop and implement a tracking system to ensure the agency completed self-assessment 3 to 6 months prior to the expiration date of the Certificate of Compliance. Upon completion of the self-assessment, the CEO will review and cross reference with the expiration date of the Certificate of Compliance to ensure timely completion. Within 30 days of receipt of the plan of correction, the CEO will train all staff responsible of completing the self-assessments on the tracking system to ensure timely completion. Documentation of training shall be kept. (AS 11/8/16)] |
09/28/2016
| Implemented |