Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | The kitchen cabinets located over the stove were found greasy to the touch. | Clean and sanitary conditions shall be maintained in the home. | The kitchen cabinets cleaned of grease. See attachments # 47. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿kitchen counter and cabinets are free of grease.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. |
07/23/2019
| Implemented |
6400.67(a) | The kitchen countertop was found damaged | Floors, walls, ceilings and other surfaces shall be in good repair. | Program Director has requested quote for counter top replacement. See attachments # 46. The Program Manager has placed cutting boards in the home. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿Kitchen counters are free of damage.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. |
09/09/2019
| Implemented |
6400.67(b) | The living room sofa had torn covers. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program Director has ordered new furniture. To be delivered by 9-19-19. See attachments #45. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿all furniture is clean & in good repair.¿ Form to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. |
09/19/2019
| Implemented |
6400.67(b) | The bathroom shower rod had endcaps that were rusted. | Floors, walls, ceilings and other surfaces shall be free of hazards. | : Shower rod and end caps were replaced. See attachments # 43. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿Shower area is clean.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. |
07/23/2019
| Implemented |
6400.181(a) | Individual #1's record did not contain an assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | All Program Specialist are re-trained regarding 6400.181 (a),(f)
It is the responsibility of the Residential Program Specialist to confirm the completion of the initial and annual assessment for individuals. This includes individuals who are new admissions to the residential program.
The Residential Program will continue monthly Case Record Review process in order to maintain compliance with regulations. See Attachment #41.
The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All Program Specialist will be responsible to make all corrections and report to Residential Assistant Director a monthly update on progress towards compliance. See 2019 Assessment, Attachment # 42. |
09/09/2019
| Implemented |
6400.213(1)(i) | Individual #1's record was missing Religious affiliation.
Individual #1's record was missing identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | All Program Specialist were re-trained regarding 6400.213(1) (I) and (I) (iv) on 7-31-19. CS, Quality Assurance Director, provided instruction. It is the responsibility of Residential Program Specialist to confirm the completion of Personal Information form for individuals. This form is printed from CADES EPESI electronic data system. The Residential Program will continue monthly CASE Record Review process in order to maintain compliance. Thirty records will be reviewed monthly. Every chart is to be reviewed quarterly. 94 records reviewed: 89% compliance (Identifying Marks), 64% compliance (religion) as of 8-30-19. The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All Program Specialist are responsible to make all corrections and report to Residential Assistant Director monthly on progress towards compliance. Individual #1 Personal Information was updated and includes Religion and Identifying marks. See attachment Broadleaf # 40 and Procedure #41. |
08/22/2019
| Implemented |