| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The license for this chapter expired on 10/15/2019. A self-assessment wasn't completed until 10/10/2019. | 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.
| a. The provider¿s Operations Director will ensure that a self-assessment schedule is created, ensuring that all homes have a completed self-assessment at least 3 times per year. This schedule will be created and implemented by 11/15/19.
b. As the self-assessments were completed for all of the homes in October 2019, the schedule will begin in January 2020.
c. Self-assessments will be completed by Program Specialists, as well as the Operations Director when necessary.
d. Any non-compliant findings will be addressed and remedied upon discovery.
e. Self-assessments of all group homes will be made available to licensing representatives whenever necessary. |
11/15/2019
| Implemented |
| 6400.73(a) | There are more than 2 steps leading up through the Bilco door at this residence. There is no handrail at this exit. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | a. The provider shall ensure that each ramp, interior stairway, and outside steps exceeding two steps shall have a well-secured handrail, in compliance with 6400.73(a)
b. The Operations Director and Program Specialists shall visually inspect all ramps, interior stairways, and outside steps, including Bilco doors, on a routine and ongoing basis. Instances of noncompliance will be reported and corrected by creating a work order for the maintenance department through the maintenance reporting system, Manager Plus.
c. The provider¿s Operations Director, Laura Mashack, created a work order to install the missing railing at the Bilco doors at 4440 Green Tree Road. The provider¿s head of the maintenance department installed the railing on 10/28/19. |
10/28/2019
| Implemented |
| 6400.82(f) | Hand soap was not accessible in either bathrooms at this residence. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | a. Immediate correction made on 10/23/19, as residential Program Supervisor JC purchased non-poisonous soft soap and placed them in all bathrooms of the home.
b. To prevent reoccurrence of this issue, Regional Director CM purchased a bulk order of non-poisonous soft soap on 10/28/19, to be given out for each group home. The bulk order has been set up for auto-delivery every 2 months.
c. If the 2 month auto-delivery is not as frequent of a delivery as need be, the auto-delivery will be changed to monthly.
d. All residential program supervisors, Program Specialists, and the Operations Director were made aware of the bulk order, as well as instructions for ensuring that they have at least one bottle of this soap per bathroom of the home at all times. |
10/28/2019
| Implemented |
| 6400.110(e) | The smoke detectors were not interconnected with each other at this residence. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | a. Operations Director Laura Mashack created a maintenance work order to fix the interconnected smoke detectors on 10/24/19.
b. Until the interconnected alarms could be fixed, awake overnight staff were made aware of the issue, performing checks throughout the night to ensure consumer safety.
c. The head of the maintenance department, Mark Daniels, fixed the smoke detectors and corrected the problem on 10/28/19.
d. During monthly fire drills, staff will check that all smoke detectors are interconnected and working properly, both in the basement and on the main floor. |
10/28/2019
| Implemented |