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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | There were leaves caught in the gutters, enough to be visible from the walkway, and likely to block rainwater effectively draining away from the home | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | What was done immediately to correct the specific issue cited?
A maintenance request work order was submitted for the leaves around the gutter and driveway to be removed. On 11/16/22 this was resolved.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change.
When will the change be made?
Gutters and driveway were cleaned on 11/16/22. Additionally, the weekly residential site checklist and its process are implemented as of 1/13/2023.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/17/2022; all exterior surfaces and grounds must be well maintained, free of hazardous material, and in good repair. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #1 |
11/16/2022
| Implemented |
| 6400.82(f) | There was no hand towel in the main bedroom bathroom. | 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. | What was done immediately to correct the specific issue cited?
A hand towel was placed in the bathroom on 11/17/2022.
What specific change will be made?
All staff and management are required to attend Quarterly Regulatory Workshops facilitated by the Quality Improvement Department. A variety of topics are discussed each quarter, all specific to the regulations followed. Household common areas and spaces specific to the individual(s) are expected to meet the regulatory and agency standards. The Site Supervisor is responsible for conducting a weekly site inspection and completing the Weekly Residential Site Checklist. All staff are responsible for recognizing violations, areas in need of improvement, and following the reporting process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and installation of items and/or submission of a maintenance request. If the matter requires maintenance, the Real Estate Department (RED) is responsible for providing updates and follow through. If the matter can be resolved by the Program, the Site Supervisor is responsible for the resolution. If unresolved within one (1) week from the date of discovery, the Program Director is responsible to address the Site Supervisor regarding the status, delay in resolution, and plan of action. If unresolved within two (2) weeks from the date of discovery, the Regional Director is contacted to either: escalate the matter to RED or escalate the matter to the Program Director to address and resolve immediately. Program Director and Site Supervisor will ensure that any unresolved area(s) of concern, do not pose a health and/or safety risk to the Participants or staff.
Who (by title) will make the change?
Program Director and Site Supervisor will be responsible for making the change
When will the change be made?
Changes went into effect on 11/17/22 when the appropriate supplies were placed in the bathroom.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete thorough site inspections weekly. Site Supervisors submit checklists to their Program Director, who ensure receipt and review of each. On a quarterly basis, Program Directors complete Quarterly Residential Site Verification Visits. This requires an in-depth inspection of the residence while comparing the findings to the Weekly Residential Site Checklists. All areas of non-compliance require the Site Supervisor, or designee, to adhere to the process identified to ensure resolution which includes but is not limited to: submission of maintenance requests, follow up and through with persons responsible, and ensure resolution.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/17/2022 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. All staff are aware that any regulatory violation requires the above-mentioned process to be immediately followed through resolution. Site Supervisors are aware that site inspections and the resolution of all violations is their responsibility. All Site Supervisors have been trained and have completed a site inspection utilizing the revised checklist and process.
Attachment #1.1 |
11/17/2022
| Implemented |
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