| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's ISP states they are unaware of poisons, and poisons in the kitchen were found unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. What was done immediately to correct the specific issue cited?
All items were removed from the cabinet under the sink on 12/12/18.
2. What specific change will be made?
Changes were made to have all poisonous materials placed in a locked area at all times. The staff are conducting weekly visual checks and monthly checks are completed by the site supervisor using the monthly residential checklist to ensure all poisons are locked.
3. Who (by title) will make the change?
Residential staff and site supervisor
4. When will the change be made?
The change was made on 12/12/18 upon discovery of the poisonous materials being in an unlocked area.
5. What system has been implemented to make sure the same violation does not occur again?
Residential staff completes a daily visual inspection of ensuring all poisons are not in unlocked areas at any time. Monthly reviews/inspections are conducted by the site supervisor to ensure all hazardous supplies, and equipment are properly stored or equipment repaired or replaced.
6. What education and training has been provided to staff?
The importance of having all poisons locked at all times was reviewed with all staff to ensure the health and safety of the participants.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Residential staff completes visual checks daily/weekly to ensure all poisons are locked after each use. Site supervisors complete visual checks weekly and completes a monthly check using the monthly residential checklist. The checklist is then reviewed with the site supervisor by the program director for any areas of non-compliance. The program director verifies all areas on the checklist during quarterly site visits. |
12/12/2018
| Implemented |
| 6400.62(d) | The garage storage shelves had cleaning supplies and food stored in adjoining shelves. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | 1. What was done immediately to correct the specific issue cited?
All food supplies were removed and the cabinet was disposed in the trash. Notice posted in area advising staff that all poisonous materials must be stored separate from food.
2. What specific change will be made?
All food and food storage items will be stored separate from poisonous materials.
3. Who (by title) will make the change?
Program Directors and Site Managers.
4. When will the change be made?
Immediately and ongoing thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Management is responsible for ensuring all food and food storage items are stored separate from food. Compliance with this regulation will be monitored through completion of Monthly Residential Checks.
6. What education and training has been provided to staff?
Managers receive training on the completion of the Monthly Residential site checklist at the time of their orientation. Managers receive follow up education and training at the time of their monthly supervisions when the Monthly Residential Site Checklist is reviewed by the Program Director.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Managers are required to inspect service locations for compliance on a monthly basis. The information recorded on the Monthly Residential Site Checklist is verified quarterly when the Program Director (Manager) completes quantitative record reviews and Residential Spot Checks. During monthly supervision when the Monthly Residential Site Checklist is submit, supervisors and managers are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. |
12/16/2018
| Implemented |
| 6400.64(a) | The kitchen cabinet above the range was found to have grease on the cabinet. | Clean and sanitary conditions shall be maintained in the home. | 1. What was done immediately to correct the specific issue cited?
Home Coordinator and direct care staff cleaned the surfaces in the kitchen and other areas where grease had collected using degreaser.
2. What specific change will be made?
The staff sign-off on a daily chore list identifying areas that were cleaned which includes bathroom, kitchen, bedrooms, living space and dining area. Home Coordinator is reviewing chore chart weekly to ensure cleanliness of site.
3. Who (by title) will make the change?
Home Coordinator reviews chore sheets on a weekly basis. Program Director reviews chore sheets on a monthly basis during supervision along with the Monthly Residential Site Checklist. Random spot checks are completed by administrative staff on a quarterly basis.
4. When will the change be made?
December 12, 2018 and ongoing
5. What system has been implemented to make sure the same violation does not occur again?
Daily chore check list are being reviewed weekly by manager to ensure task are being completed.
Cleanliness of the site is being reviewed on a monthly basis during individual supervisions of direct care staff and during monthly staff meetings. Residential site checklist are completed by Home coordinator and reviewed monthly by Program Director.
6. What education and training has been provided to staff?
Site supervisor and staff counseled on the importance of maintaining cleanliness and compliance with 6400 regulations and Horizon House standards.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
8. Program Directors are required to visit each service location on a quarterly basis to inspect service locations for cleanliness. The information recorded on the Monthly Residential Site Checklist is also verified quarterly when the Program Director completes quantitative record reviews and Residential Spot Checks. During monthly supervision when the Monthly Residential Site Checklist is submitted, home coordinators are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. |
12/12/2018
| Implemented |
| 6400.67(b) | The storage shelving in the garage, holding cleaning supplies, was rusted and unlocked. | Floors, walls, ceilings and other surfaces shall be free of hazards. | 1. What was done immediately to correct the specific issue cited?
Management cleared the cabinet of all items and disposed of the cabinet for trash pickup.
2. What specific change will be made?
When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery. The supervisor will keep the PD apprised of any issues not resolved within 30 days. The supervisor has informed all staff of the importance of reporting observed maintenance issue immediately so that steps may be taken to resolve them.
3. Who (by title) will make the change?
The supervisor completes the monthly site residential checklist. The PD reviews the checklist for outstanding issues during monthly supervision. The PD completes a physical walk through of service location quarterly to verify the information documented on the monthly site checklist.
4. When will the change be made?
The change was made December 12, 2018.
5. What system has been implemented to make sure the same violation does not occur again?
Increased oversight by site supervisor, staff, and Program Director, documenting discovery and ensuring repairs are completed in a timely manner.
6. What education and training has been provided to staff?
The supervisor will attend Real Estate training annually. The information from the training will be used to remind staff of ensuring all areas of the home are safe and free from hazards.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery. The supervisor will keep the PD apprised of any issued not resolved within 30 days. The PD will follow up with maintenance as necessary until the issue is resolved. The supervisor has informed all staff of the importance of reporting observed maintenance issues immediately so that steps may be taken to resolve them. |
12/12/2018
| Implemented |
| 6400.76(a) | There were 2 chairs in the kitchen that were loose at the joints. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. What was done immediately to correct the specific issue cited?
A maintenance request was submitted and the chair legs were repaired on Jan. 8, 2019
2. What specific change will be made?
Home Coordinator routinely assesses furniture to check for any areas of noncompliance and/or if possible resolve the issue, ie: Purchasing new furniture, purchasing furniture pieces, etc. Home Coordinator completes visual checks weekly and uses the monthly site checklist during monthly inspections.
3. Who (by title) will make the change?
Home Coordinator
4. When will the change be made?
The change was made Jan. 2019
5. What system has been implemented to make sure the same violation does not occur again?
During monthly supervision, Program Director reviews monthly site checklist with Home Coordinator regarding any areas of non-compliance. Should and furniture or equipment needs replacing or repaired the proper paperwork is submitted the maintenance dept or purchasing dept.
6. What education and training has been provided to staff?
Staff counseled on recognizing that all issues whether great or small should be properly addressed and the need for all furniture and equipment must be in good condition. Also, as issues arise to forward concerns to management so that the proper steps can be taken. ex. purchasing new furniture, repairing broken furniture, etc.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery. The supervisor will keep the PD apprised of any issued not resolved within 30 days. The PD will follow up with maintenance as necessary until the issue is resolved. The supervisor has informed all staff of the importance of reporting observed maintenance issues immediately so that steps may be taken to resolve them. |
01/08/2019
| Implemented |
| 6400.80(b) | The exterior porch off of the kitchen had worn and splintered handrails. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | 1. What was done immediately to correct the specific issue cited?
A request was submitted the Horizon House maintenance department and contact made with the property management. The area was sand and repainted on 12/26/18.
2. What specific change will be made?
Residential staff completes visual checks weekly of equipment inside and outside areas. Should any area need to be repaired or replaced, communication is made with the supervisor and/or the program director. A request is then submitted to the Real Estate Dept.
3. Who (by title) will make the change?
Residential Staff and site supervisors
4. When will the change be made?
The change was made on 12/12/18
5. What system has been implemented to make sure the same violation does not occur again?
When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery
6. What education and training has been provided to staff?
Residential Site Checklist and EMAINT was reviewed with Site Manager to ensure that the site is inspected thoroughly each month and necessary follow up is done to ensure the repairs are completed in a timely manner.
Site Managers and Program Directors will attend Real-Estate training class annually.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
When completing the monthly site checklist the supervisor will document issues not captured on the site checklist. If issues are observed prior to the completion of the monthly site checklist the supervisor will request repairs through maintenance request immediately upon discovery. The supervisor will keep the PD apprised of any issues not resolved within 30 days. The PD will follow up with maintenance as necessary until the issue is resolved. The supervisor has informed all staff of the importance of reporting observed maintenance issues immediately so that steps may be taken to resolve them. |
12/12/2018
| Implemented |
| 6400.101 | The exterior porch off the kitchen had a gate sagging onto the porch causing a blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1. What was done immediately to correct the specific issue cited?
A maintenance request was submitted to have the gate repaired to easy exit from home. The gate was shaved down from the bottom to allow for the gate to close freely. The repair was completed on 12/26/2018
2. What specific change will be made?
The change is for staff to complete visual checks of all egress on a daily basis to ensure a safe egress from all exits of the home. Any items blocking are to be removed immediately. Any structural repairs are submitted on a maintenance request at the time of discovery.
3. Who (by title) will make the change?
Residential staff and Site Supervisor
4. When will the change be made?
The change was made upon discovery, 12/12/2018
5. What system has been implemented to make sure the same violation does not occur again?
Residential staff completing daily visual checks and removing any items that may be a hazard to and from all exits; contacting the site supervisor immediately for any areas that may need a maintenance request submitted. Supervisor will alert the Program Director of the area of non-compliance. The site supervisor and program director follows up with the Real Estate department to ensure the repair is completed.
6. What education and training has been provided to staff?
There was a review with staff on the importance of ensuring all means of egress are clear and free at all times, which includes doors and gates are not difficult to open.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Residential staff completing daily visual checks and removing any items that may be a hazard to and from all exits; contacting the site supervisor immediately for any areas that may need a maintenance request submitted. This will also be monitored from the monthly residential checklist completed by the site supervisor. Program Director reviews the checklist and verifies completion of all areas during quarterly site visits. |
12/12/2018
| Implemented |