| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(e) | The trash can, over 18 inches high, containing Individual #2's used, recycling cans was in the garage of the home, not equipped with a lid. The trash can not equipped with a lid was sitting next to a large, industrial, 64-gallon trash can. The trash can without a lid was more than half the height of the industrial trash can. | Trash receptacles over 18 inches high shall have lids. | The trash can utilized by the person served in the home as a receptacle for recyclable cans has been removed and replaced with one with a lid. Photograph has been submitted for review. (#23) Program Managers were trained on 6400.64(e) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance record are submitted for review. Program Managers will ensure all trash cans over 18 have lids. The Program Specialist and Operations Directors will continue to complete walkthroughs of the homes periodically to ensure lids on all trash cans. Monitoring will also be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/09/2021
| Implemented |
| 6400.80(a) | The front, cement walkway leading to the home was cracked in one location, across the entire width of the walkway, approximately 2 and ½ feet long. The crack caused one side of the cement walkway to raise higher than the other section of walkway, creating a tripping hazard.
The exterior, cement walkway leading to the exterior cement landing pad off of the porch, was not level and created numerous tripping hazards. The cement walkway was comprised of individual cement sections that had risen and fallen from the level ground, creating areas where corners of cement were protruding in the air and sticking down in the ground.
The exterior, cement walkway dropped off from the exterior cement landing pad, approximately 3 inches in one location. There weren't any visual cues to notify someone of the uneven surface or that it dropped down a few inches. The individuals use this egress route to evacuate the home during fire drills and night and in day light. This uneven surface created a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The Facilities Director, Operations Director, and Director of Quality Assurance & Training are scheduled to survey the homes cement walkway once weather permits. Upon review, the Facilities Director will obtain bids from local concrete finishers. Estimates will be submitted, and an appropriate resolution will be obtained. The drop off area from the cement landing pad has been painted to highlight the drop until the construction is completed. Photograph is submitted for review The Operations Director will train the Program Manager and staff at the Valley Road CLA on the following: Staff will ensure entering and exiting the home during fire drills is safe until the issues are resolved. The person pulling the alarm will immediately station themselves at egress and staff will also follow to ensure the persons we serves safety.
The Director of Quality Assurance & Training will submit updates to the lead surveyor until the walkway issues are resolved. |
05/01/2021
| Implemented |
| 6400.145(3) | The home's written emergency medical plan did not include the emergency staffing plan in place in the event of a medical emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on March 9, 2012. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individuals #1 & 2 forms have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections |
03/11/2021
| Implemented |
| 6400.32(s) | During the 1/27/21 remote inspection of the home, Individuals #1 and #2 reported that they do not have a key to the door of their home and weren't offered a key. Both individuals reported to the Department and staff present during the inspection, that they would like to have a key to their home so they can enter, exit and lock and unlock the door to their home. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.32(s) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance record have been submitted for review.(#14) A Key Request form and a Key Agreement form, used with mandatory Teams meetings, have been created. Both forms have been submitted for review. Individual #1 and #2 have signed the Key Request form and it is submitted for review, also. The Program Managers are required to utilize the Key Request form for all individuals assigned who request for a key by March 15, 2021 and submit copy to the Program Specialist. The form will be kept in the individuals permanent chart. The Program Specialists are required to utilize the Key Agreement form with attached team meeting minutes for all other individuals within the agency. Team meetings will be schedule and/or completed by 03/31/2021. Program Specialists will submit the meeting schedule to the Operations Director once completed. The Operations Director will participate in team meetings to: 1) ensure all alternative key options are discussed, 2) the individual is part of the meeting unless they indicate otherwise, 3) the team is in agreement. All Key Agreement Team Meetings forms will be submitted to the Quality Assurance & Training department to ensure all individuals needs have been addressed. The Key Agreement Team Meeting form will be kept in the individuals permanent chart. To ensure no further infractions occur, the Quality Assurance & Training Associate will review forms during their biannual inspections. |
03/31/2021
| Implemented |