|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Black substance consistent with mold around tub must be corrected. | Clean and sanitary conditions shall be maintained in the home. | What was done immediately to correct the specific issue cited?
The bathtub was assessed and recalked by maintenance on 1/3/2023.
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?
Change was implemented immediately on 11/22/2022 and 1/3/2023.
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 11/22/2022; Clean and sanitary conditions shall be maintained in the home 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 #21.3 |
01/03/2023
| Implemented |
| 6400.67(a) | The chipped tile flooring at the step leading into the den area from the kitchen-poses a tripping hazard and needs to be repaired. | Floors, walls, ceilings and other surfaces shall be in good repair. | What was done immediately to correct the specific issue cited?
Program Director submitted a maintenance request on 11/15/2022. On 1/12/2023 this matter 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?
Change was implemented on 1/12/2023.
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 11/22/2023. 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 #21.1 |
01/12/2023
| Implemented |
| 6400.73(a) | Hand railing leading to bedrooms is loose and must be tightened and secured. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | What was done immediately to correct the specific issue cited?
Program Director submitted maintenance work order submitted 11/15/22. The handrail was tightened on 12/7/2022
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 11/22/2022 and 12/7/2022 when service was completed.
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 11/22/2022; each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. . 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 #21.4 |
11/22/2022
| Implemented |
| 6400.76(a) | The Kitchen cabinets are broken and worn. | Furniture and equipment shall be nonhazardous, clean and sturdy. | What was done immediately to correct the specific issue cited?
Maintenance work order submitted 11/15/22 by Program Director for replacement cabinets to be installed. The kitchen cabinets were repaired on 12/20/2023. The remaining pieces have been ordered and will be installed on or before 2/3/2023.
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?
Change was implemented on 11/22/2022 and 12/20/2022.
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 11/22/2022. 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 #21 |
11/22/2022
| Implemented |
| 6400.76(a) | Hall bathroom shower rod is rusted and must be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | What was done immediately to correct the specific issue cited?
Maintenance work order submitted 11/15/22 by Program Director. The shower rod was replaced on 1/3/2023
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?
Change was implemented on 11/22/2022 and on 1/3/2023.
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 11/22/2022; Furniture and equipment shall be non-hazardous, clean, and sturdy. 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 #21.2 |
11/22/2022
| Implemented |
| 6400.77(c) | The first aid book is not in the first aid kit, it was replaced during inspection. | A first aid manual shall be kept with the first aid kit. | What was done immediately to correct the specific issue cited?
On 11/15/2022 the first aid kit manual was replaced in the first aid kit.
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?
Change went into effect on 11/15/2022 and 11/22/2022
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 11/22/2022; a first aid manual shall be kept with the first aid kit. 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 #21.5 |
11/15/2022
| Implemented |
| 6400.110(a) | The smoke detector in the basement is inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | What was done immediately to correct the specific issue cited?
Site Supervisor submitted a maintenance work order request on 11/14/2022. The matter was resolved on 11/22/2022. The smoke detector is operable.
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?
Change was implemented immediately on 11/14/2022 and 11/22/2022.
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 11/22/2022. 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 #21.6 |
11/14/2022
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The front and rear porch lights of the home were inoperable at the time of inspection. Staff on site replaced the lightbulbs during the site inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1. What was done immediately to correct the specific issue cited?
Front porch light bulb was immediately replaced. Verification that bulb was replaced and operable was completed by inspector on November 17, 2021.
2. What specific change will be made?
A Daily Shift Checklist has been created that includes checking to ensure that light fixtures are in working order. Extra light bulbs are present at the site should a light bulb need to be replaced.
3. Who (by title) will make the change?
Manager¿s and Program Directors.
4. When will the change be made?
November 17, 2021 and ongoing thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
All residential staff is responsible for completing the Daily Shift Checklist to ensure all lights are operable. The Site Supervisor will review the Shift Checklists and sign off to ensure that all items in need of correction have been addressed
6. What education and training has been provided to staff?
Staff Meeting was conducted with all during which time all were informed of the need to always have sufficient lighting throughout the service location per 6400.66. All staff were instructed to replace blown out bulbs immediately upon discovery going forward
Attachment #10.3 |
11/17/2021
| Implemented |
| 6400.67(a) | A curtain rod located in Individual#2's bedroom was significantly bowed. This curtain rod was repaired prior to the conclusion of the inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. What was done immediately to correct the specific issue cited?
This curtain rod was repaired prior to the conclusion of the inspection.
2. What specific change will be made?
The Monthly Residential Site Checklist is done by the Site Supervisor. It was updated to include curtain rods that are in disrepair. Any curtain rods that are out of compliance will immediately be repaired or replaced by the Site Supervisor.
3. Who (by title) will make the change?
Site Supervisor, Program Director
4. When will the change be made?
On November 18, 2021 the curtain rod was repaired
5. What system has been implemented to make sure the same violation does not occur again?
The Monthly Residential Site Checklist has been completed by the Site Supervisor to check various areas of the site, and this will now include the condition of curtain rods. The Site Supervisor will immediately address all curtain rods in need of repair or replacement and follow up to ensure resolution.
6. What education and training has been provided to staff?
Program Director met with the Site Supervisor to review items out of compliance based on the Monthly Residential Site Checklist and to ensure that they are being addressed.
Attachment #10.7 |
11/18/2021
| Implemented |
| 6400.72(b) | The window in the second-floor main hallway bathroom was not in good repair at the time of inspection. The window was incapable of remaining in the open position; when the window was raised into the open position and released, it slammed shut quickly, posing a potential hazard. | Screens, windows and doors shall be in good repair. | 1. What was done immediately to correct the specific issue cited?
HH Real Estate Staff was notified of the safety hazard presented at the time of inspection, and the repairs were made on 12/22/21.
2. What specific change will be made?
A Daily Shift Checklist was created so staff can conduct a review of the site on each shift, and submit a work order for each area in disrepair to the Real Estate Dept. within Horizon House.
3. Who (by title) will make the change?
Horizon House Real Estate Operations Director, Site Manager, Program Director.
4. When will the change be made?
On December 22, 2021
5. What system has been implemented to make sure the same violation does not occur again?
Residential staff is responsible for completing the Daily Shift Checklist. The Site Supervisor will review the Shift Checklists and sign off to ensure that all items in need of correction have been addressed. Managers are to submit a work order for any area found to be in disrepair immediately upon notice.
6. What education and training has been provided to staff?
Program Director met with site Manager following site inspection and reviewed process for submitting work orders for physical site areas in need of repair.
Attachment #10.1 |
12/22/2021
| Implemented |
| 6400.81(k)(4) | There was no chest of drawers in Individual#1's bedroom. A chest of drawers was procured for the individual prior to the conclusion of the inspection. | In bedrooms, each individual shall have the following: A chest of drawers. | 1. What was done immediately to correct the specific issue cited?
A chest of drawer was already ordered for this bedroom but did not yet arrive. A chest of drawers was procured for the individual prior to the conclusion of the inspection.
2. What specific change will be made?
The Monthly Residential Site Checklist is done by the Site Supervisor. Any area that is out of compliance will immediately be addressed by the Site Supervisor.
3. Who (by title) will make the change?
Site Supervisor, Program Director
4. When will the change be made?
On November 18, 2021 the chest of drawer arrived for the bedroom
5. What system has been implemented to make sure the same violation does not occur again?
The Monthly Residential Site Checklist has been completed by the Site Supervisor to check various areas of the site, and this includes participants having chest of drawers in their bedroom. The Site Supervisor will immediately address all items in need of correction and follow up to ensure resolution.
6. What education and training has been provided to staff?
Program Director met with the Site Supervisor to review items out of compliance based on the Monthly Residential Site Checklist and to ensure that they are being addressed.
Attachment #10.4 |
11/18/2021
| Implemented |
| 6400.81(k)(6) | There was no mirror in Individual#1's bedroom. A mirror was obtained for the individual prior to the conclusion of the inspection | In bedrooms, each individual shall have the following: A mirror. | 1. What was done immediately to correct the specific issue cited?
A mirror was already ordered for this bedroom but did not yet arrive. A mirror was procured for the individual prior to the conclusion of the inspection.
2. What specific change will be made?
The Monthly Residential Site Checklist is done by the Site Supervisor. Any area that is out of compliance will immediately be addressed by the Site Supervisor.
3. Who (by title) will make the change?
Site Supervisor, Program Director
4. When will the change be made?
On November 18, 2021 the mirror arrived for the bedroom
5. What system has been implemented to make sure the same violation does not occur again?
The Monthly Residential Site Checklist has been completed by the Site Supervisor to check various areas of the site, and this includes participants having a mirror in their bedroom. The Site Supervisor will immediately address all items in need of correction and follow up to ensure resolution.
6. What education and training has been provided to staff?
Program Director met with the Site Supervisor to review items out of compliance based on the Monthly Residential Site Checklist and to ensure that they are being addressed.
Attachment #10.5 |
11/18/2021
| Implemented |
| 6400.82(f) | At the time of inspection, no soap could be located within the second-floor main hallway bathroom. Soap was placed in the bathroom prior to the conclusion of the inspection. | 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. | 1. What was done immediately to correct the specific issue cited?
At the time of discovery, soap was placed into the bathroom for use.
2. What specific change will be made?
Upon the beginning of each shift, staff on duty will ensure that soap is in the bathroom for the participants and all staff use. A staff on each shift will complete a Shift Checklist that includes checking that soap is in each bathroom. The availability of bathroom soap is also captured on the Monthly Residential Site Checklist that is done by the Site Supervisor. Access to the soap and back up supplies will always be available to staff at all times, who will ensure that it is placed in the bathrooms as needed.
3. Who (by title) will make the change?
The site supervisor will be responsible to ensure soap is always available and placed in the bathroom.
4. When will the change be made?
On November 17, 2021 soap was immediately placed in the bathroom of the home.
5. What system has been implemented to make sure the same violation does not occur again?
A Daily Shift Checklist has been developed for staff on each shift to check various areas of the site, and this includes soap in the bathroom. The Site Supervisor will review the Shift Checklists and sign off to ensure that all items in need of correction have been addressed. Unless the assessment and the individual support plan specify otherwise, soap will be placed in all bathrooms in the home.
6. What education and training has been provided to staff?
The staff was educated by the Program Director on the importance of having hand soap in the bathroom at all times for sanitary reasons on 12/22/21.
Attachment #10.6 |
11/17/2021
| Implemented |
| 6400.32(r) | Individual#1did not have a lock on the bedroom door or doorknob; therefore, the individual was unable to exercise the right to lock the bedroom door. | An individual has the right to lock the individual's bedroom door. | 1. What was done immediately to correct the specific issue cited?
A lock was placed on the individual¿s bedroom door prior to the conclusion of the inspection.
2. What specific change will be made?
The Monthly Residential Site Checklist is done by the Site Supervisor. Any area that is out of compliance, include missing locks on bedroom doors, will immediately be addressed by the Site Supervisor.
3. Who (by title) will make the change?
Site Supervisor, Program Director
4. When will the change be made?
On November 18, 2021 a lock was placed on the door
5. What system has been implemented to make sure the same violation does not occur again?
The Monthly Residential Site Checklist has been completed by the Site Supervisor to check various areas of the site, and this includes participants having a lock on their bedroom door. The Site Supervisor will immediately address all items in need of correction and follow up to ensure resolution.
6. What education and training has been provided to staff?
Program Director met with the Site Supervisor to review items out of compliance based on the Monthly Residential Site Checklist and to ensure that they are being addressed.
Attachment #10.2 |
11/18/2021
| Implemented |
| 6400.46(d) | First aid training for staff member#1 was not completed within the 6 month timeframe after initial employment. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | 1. What was done immediately to correct the specific issue cited?
The Program Director registered this staff for their First Aid training on 12/22/21.
2. What specific change will be made?
QI developed a training tracker in order to monitor and ensure that staff have completed their required trainings on time. This tracker will be reviewed in the Quality Council meetings monthly.
3. Who (by title) will make the change?
Site Supervisor, Program Director, Regional Director, Chief Services Officer of DS, Learning and Development Manager
4. When will the change be made?
12/22/21
5. What system has been implemented to make sure the same violation does not occur again?
The QI department created a training tracking system that has color coded indicators to notify the Program Director when staff trainings are almost due or overdue. The date on the Training Tracker Spreadsheet will automatically change to yellow if the trainings are due within the next 60 days, change dates to red for trainings that are past due, and show green for training dates that are current. This visual color coded system will easily alert Site Supervisors and Program Directors on what trainings are current, coming due, or past due. This tracker will be maintained by the Learning and Development Manager who will email it monthly and also present it in the Quality Council Meetings monthly.
6. What education and training has been provided to staff?
The program director reviewed the 6400.46d regulation with the site supervisor and stressed the importance that staff should complete their first aid training 6 since months of hire and renew annually thereafter.
Attachment #10 |
12/22/2021
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The wall and ceiling near where the refrigerator was located in the kitchen was stained with a brown substance. | Clean and sanitary conditions shall be maintained in the home. | 1. What was done immediately to correct the specific issue cited?
The wall and ceiling near the refrigerator was cleaned immediately after the physical site walkthrough concluded. State inspector visited the home on October 20, 2017 and acknowledged the area had been cleaned.
2. What specific change will be made?
Supervisors has directed staff to deep clean areas prone to grease and dust collection on a monthly basis.
3. Who (by title) will make the change?
Supervisors and managers are responsible for ensuring all areas of the site are clean and sanitary. Program Director and Real Estate staff will complete random spot checks on a quarterly basis which includes verification all areas of the program are clean and sanitary.
4. When will the change be made?
October 20, 2017 and ongoing, thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors and managers are responsible for completing the Monthly Residential Site Checklist. When completing the Monthly Residential Site Checklist the supervisor checks all areas of the home for compliance including a check of the physical site. During the check, the supervisor is responsible for answering questions relative to the cleanliness of the site. Supervisors are responsible for immediate follow up on any areas of non- compliance.
6. What education and training has been provided to staff?
Supervisors receive training on the completion of the Monthly Residential site checklist at the time of their orientation. Supervisors 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.
Direct service employees receive training regarding site cleanliness and their responsibility to complete the shift responsibility list during their initial on-site orientation.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Program Directors are required to visit each service location on a monthly 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, supervisors and managers are reminded to ensure the accuracy of their report and advised as to how to implement any needed corrective actions. |
10/19/2017
| Implemented |
| 6400.76(a) | Two kitchen chairs had torn seat cushions. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. What was done immediately to correct the specific issue cited?
Since there was only a small tear in the two chairs, black duct tape was placed over the tears in the chairs as a temporary fix. New furniture was purchased (Attachment 1).
2. What specific change will be made?
Supervisors and managers routinely assess furniture to check for fraying materials. If the furniture is deemed beyond repair, the furniture will be discarded and new furniture will be purchased.
3. Who (by title) will make the change?
Supervisors and 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?
During monthly supervision, Program Director will review expectations with Home Coordinator in regards to properly monitoring the physical site.
6. What education and training has been provided to staff?
Staff counseled on the expectations of inspectors when they inspect residential homes. Emphasis of the training was placed on staff recognizing that all issues whether great or small should be properly addressed. Also, as issues arise staff was advised to forward concerns to management so that the proper steps can be taken. ex. purchasing new dresser, etc.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Home Coordinator will conduct ongoing monitoring the participants¿/site furniture and address any concerns on a continuous basis. Home Coordinator will file/forward copies of any maintenance/purchase requests when they are about to be or have been completed as a follow-up to the action plan. This type of record keeping will provide a snap shot of any gaps in the process of completing maintenance requests and if any support, training, etc is needed. |
10/19/2017
| Implemented |
| 6400.101 | The exit door located off the laundry room was not able to be used due to a door alarm with no key available to turn off the alarm. | 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?
Battery was taken out of the alarm so door could be opened without alarm sounding off. A work order was submitted to have the door alarm removed from the door of the laundry room (Attachment 1).
2. What specific change will be made?
Supervisors and managers will ensure that all means of egress are passable and unobstructed at all times.
3. Who (by title) will make the change?
Supervisors, Managers, Program Directors.
4. When will the change be made?
It was made immediately and on November 8th the door alarm was completely removed from the door.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors and managers are responsible for ensuring direct service employees complete fire drills each month. At the time of the drill it is expected that all exits are checked for accessibility. Supervisors are responsible for signing off on all fire drill records. At the time of the review of the fire drill record, supervisors will again check to ensure all means of egress are passable. Supervisor¿s signature on the fire drill record indicates verification that all means of egress are unobstructed and available for egress at the time of the review.
6. What education and training has been provided to staff?
Supervisors and managers are educated on regulatory compliance during monthly supervisions and bi monthly (every other) supervisors¿ meetings. Supervisors receive training on the completion of the Monthly Residential Site Checklist at the time of their orientation. Supervisors receive follow up education and training at the time of their monthly supervisions when the Monthly Residential Site Checklist (Attachment 2) is reviewed by the Program Director. Direct service employees receive training regarding physical site compliance and their responsibility to ensure all physical site areas meet regulatory standards at the time of their initial on-site orientation.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
The completion of Fire Drills are documented Monthly Paperwork Checklist form which is completed by the Supervisor or Manager and reviewed by the Program Director at the time of monthly paperwork review. During the monthly paperwork review Program Directors will ensure the fire drill record has been signed by the supervisor/manager and confirm that the additional fire safety checks (unobstructed egress) was completed when the supervisor signed the fire drill record. |
11/08/2017
| Implemented |
| 6400.110(a) | The smoke detectors in the home were inoperable at the time of the inspection. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 1. What was done immediately to correct the specific issue cited?
A work order was submitted and the battery was replaced on October 19, 2017. The licensing inspector returned the following day to check that it was completed and confirmed that the smoke detector was operational.
2. What specific change will be made?
Supervisors and managers will ensure that the smoke detectors are being checked when fire drills are conducted. Checks of all smoke detectors will be documented on the fire drill record form. Any inoperable smoke detectors will be repaired or replaced immediately within 24 hours of discovery.
3. Who (by title) will make the change?
Supervisors, Managers, and Program Directors are responsible to assure that the routine checks and any needed replacements are completed.
4. When will the change be made?
The change was made immediately and has continued ongoing.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors and managers are responsible for ensuring fire drills are completed. Supervisors are responsible for signing off on all fire drill records. At the time of the review of the fire drill record, supervisors will again check the fire system to ensure it is operable. The supervisor¿s signature on the fire drill record indicates verification that all systems were properly working at the time of the review.
6. What education and training has been provided to staff?
Supervisors and Managers are educated on regulatory compliance during monthly supervisions and bi monthly (every other month) supervisor meetings.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
Fire Drill completions are documented on the Monthly Paperwork Checklist form which is completed by the Supervisor or Manager and reviewed by the Program Director at the time of monthly paperwork review. During the monthly paperwork review, Program Directors will ensure that the fire drill record has been signed by the supervisor/manager and confirm that the additional fire system check was completed when the supervisor signed the fire drill record. |
10/19/2017
| Implemented |
| 6400.112(i) | The fire drill documentation for 4/19/17 did not document which detector was set off during the drill. | A fire alarm or smoke detector shall be set off during each fire drill. | 1. What was done immediately to correct the specific issue cited?
A Fire Drill was completed on October 19, 2017 and the location of the detector utilized and set off was indicated on the fire drill record.(Attachment 1)
2. What specific change will be made?
Supervisors and Managers will ensure fire drills are completed at each service location on a bi-monthly basis and that all areas of the fire drill record are completed.
3. Who (by title) will make the change?
Supervisors, Managers, and Program Directors will ensure that the Fire Drill documentation is complete.
4. When will the change be made?
The change was made immediately and ongoing, thereafter.
5. What system has been implemented to make sure the same violation does not occur again?
Supervisors and Managers are responsible for ensuring fire drills are completed on a bi-monthly basis. Supervisors are responsible for signing off on all fire drill records. At the time of the review of the fire drill record, supervisors will ensure that all areas of the fire drill record have been filled in before signing off as a reviewer. The supervisor¿s signature on the fire drill record indicates verification that all areas of the form are complete at the time of the review.
.
6. What education and training has been provided to staff?
Supervisors and Managers are educated on regulatory compliance during monthly supervisions and bi monthly (every other month) supervisors¿ meetings.
7. How will we monitor to prevent reoccurrence? Include specific record keeping, ongoing monitoring activities and action plan follow-up.
The completion of Fire Drills are documented on the Monthly Paperwork Checklist form which is completed by the Supervisor or Manager and reviewed for errors /omissions by the Program Director at the time of monthly paperwork review. Monthly paperwork is reviewed one week prior to the end of the month to allow time for additional drills to be conducted and education to be provided to staff when errors on the record are noticed. |
10/19/2017
| Implemented |
|
|