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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Carpet throughout 2nd floor needs to be cleaned or replaced as it is worn in multiple areas on the steps. | Clean and sanitary conditions shall be maintained in the home. | What was done immediately to correct the specific issue cited?
Program Director submitted maintenance work order submitted 11/29/22 and carpets were replaced on 1/13/2023.
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 11/21/2022 and 12/13/2022.
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 12/13/2022. 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 #20.5 |
11/21/2022
| Implemented |
| 6400.66 | There is no lamp or lighting in the living room. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| What was done immediately to correct the specific issue cited?
Site Supervisor purchased a new lamp on 11/18/22. Lamp was placed in the living room by the Site Supervisor.
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 11/18/2022 and 11/21/2022.
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 11/21/2022. 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 #20.1 |
11/18/2022
| Implemented |
| 6400.67(a) | a. Dining area has patches of paint due to unfinished repairs to home, which must be completed.
b. 8/8/22-work order- initial contact made for repair of bathroom/kitchen etc. 8/22/22 next call, next call 11/10/22-the repair is HH's responsibility. Conversation between landlord and HH staff was determining who would be responsible for fixing the damage and no other conversations were held after august 2022. Unfinished repair to tub 11/10/22 as the water is not in use in the tub for fear of leak in kitchen, water is cut off. 8/8/22-work order submitted for painting/patchwork for kitchen due to bathroom leak. Patchwork completed 9/30/22- however, the kitchen still needs to be painted. | 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 to prioritize the unresolved painting above the bathtub. The painting of this bathroom was completed on 12/30/2022.
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?
Change was implemented on 11/21/2022 and 12/30/2022.
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 11/21/2022. 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 #20 |
11/21/2022
| Implemented |
| 6400.73(a) | The exit steps and railing in the kitchen are worn. | 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 landlord of this residence has been informed of the matter and has been given two weeks to repair the area of concern. Failure to repair this will result in the agency conducting the repairs without landlord involvement.
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 the site inspection and completing the 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 will 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 11/15/2022.
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 11/17/2022; 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 #20.2 |
11/15/2022
| Implemented |
| 6400.76(a) | The shower rod is rusted in the hall bathroom. | 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 matter was resolved on 12/13/2022
What specific change will be made?
All staff and management will be required to attend and complete quarterly regulatory workshop training with the Quality Improvement Department. A variety of topics will be discussed each quarter, all of which surround regulations, expectations, and ensuring compliance. All staff will be trained on the revised Weekly Residential Site Checklist and the expectations in completing a site inspection both formally (completing the required weekly inspection) and informally (simply recognizing regulatory areas when not completing the weekly requirement). The Site Supervisor is the primary position responsible for conducting and completing site inspections and the Weekly Residential Site Checklist. All staff are expected and responsible for recognizing regulatory violations, or areas in need of improvement and reporting those as trained. The checklist will capture all regulatory areas, including agency expectations, in need of resolve. All discovered issues and areas of concern will initiate follow-up by the Site Supervisor or designee which include the purchasing of items and/or submission of a maintenance request.
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 11/21/2022 and 12/13/2022. The revised weekly residential site checklist and its process have been implemented in all residential locations to ensure thorough inspections are completed weekly.
What system has been implemented to make sure the same violation does not occur again?
Site Supervisors are required to complete a thorough site inspection weekly using the Weekly Residential Site Checklist. Site Supervisors will submit checklists to their Program Director, who will ensure receipt and review of each residential checklist. As verification, on a quarterly basis, Program Director, and Quality Improvement and Regional Directors, when necessary, will select one (1) Weekly Residential Site Checklists per site location (that was completed by the Site Supervisor) to complete a site inspection. In the absence of a Site Supervisor, the Program Director will assume the role of the Site Supervisor, and the Regional Director will assume the role of the Program Director in the completion of the Weekly Residential Site Checklist as outline above. Should areas of non-compliance be discovered, Site Supervisors or designee are required to adhere to the Weekly Residential Site Checklist Process and address the areas of concern by: completing maintenance requests, following up with the supervisors, and ensuring that the issue is resolved.
What education and training has been provided to staff?
Staff were educated on this regulation during a staff meeting held on 11/21/2022; furniture and equipment shall be nonhazardous, clean and sturdy which includes all areas such as: shower rods and bathtubs/showers. Following the implementation of the revised Weekly Residential Site Checklist and its process, all Supervisors will be trained by Program Director on how to complete a site inspection thoroughly and accurately.
Attachment #20.3 |
11/18/2022
| Implemented |
| 6400.76(a) | The 2nd floor and basement water heaters in the bathroom were rusted. | 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 matter was resolved on 12/9/2022.
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?
Change was implemented on 11/15/2022, 11/22/2022, and 12/9/2022.
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 #20.4 |
11/15/2022
| Implemented |
| 6400.82(f) | No individual towel, paper towels, or soap were found in the 2nd floor 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?¿
Residential staff placed paper towels in the bathroom during inspection on 11/15/2022.
¿
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. In order to ensure regulatory and agency expectations and compliance, all staff will be trained on the revised Weekly Residential Site Checklist and the identified process; the expectations in conducting a site inspection both formally (completing the required weekly inspection) and informally (simply recognizing regulatory areas when not completing the weekly requirement). The Site Supervisor is responsible for conducting the site inspection and completing the checklist. All staff are responsible for recognizing regulatory violations, or areas in need of improvement, and following the reporting process as identified in the process. The checklist captures all regulatory and agency expectations. All discovered areas of concern or violation will initiate follow-up by the Site Supervisor, or designee, which includes the purchasing and implementation of items and/or submission of a maintenance request. If the matter requires maintenance attention, 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 11/16/22 when the appropriate supplies were placed in the bathroom.
5. 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 Visit. 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 11/21/2022 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 #20.7 |
11/16/2022
| Implemented |
| 6400.105 | Medium golf ball size lint found in the dryer at inspection, it was removed during inspection. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| What was done immediately to correct the specific issue cited?
At the time of inspection, on 11/15/2022, Supervisor discarded the lint found in the dryer. A sign has been posted in laundry are reminding staff to clean the lint filter after each use.
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 11/15/22.
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?
Site Supervisor was educated on this regulation during a supervision meeting held on 11/21/2022. 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 #20.8 |
11/15/2022
| Implemented |
| 6400.32(i) | Individual #12 clothes are housed in the basement due to behaviors. | An individual has the right of access to and security of the individual's possessions. | What was done immediately to correct the specific issue cited?¿¿
The assessment for participant MA reflects the need for his clothing to be stored in the basement due to behavioral damage. This was corrected on 12/2/2022. This information has been reflective in his ISP under the `Know and Do¿ section.
¿
What specific change will be made?¿
Program Specialist and Program Managers review and update assessments on an as needed basis to ensure any changes are reflective. Program Specialist is responsible to communicate these reviews, updates, or modifications to the Supports Coordinator to ensure consistency.
Who (by title) will make the change?¿
Program Specialist and Program Supervisor¿
¿
When will the change be made?¿
No change to the assessment or ISP was necessary; the information had already been reflective.
¿
What system has been implemented to make sure the same violation does not occur again?¿
Upon review and revision, if necessary, of the assessment, Program Specialist or Program Supervisor is responsible to ensure all areas of the participant¿s assessment is filled in correctly. Additionally, Program Specialist is responsible to ensure the ISP is reflective of the same information. Any incomplete or incorrect areas in the assessment will be immediately addressed by Program Specialist and Program Supervisor.¿
What education and training has been provided to staff?¿
Program Specialists were reminded of the need to ensure all personal information for participants is reviewed and updated on at least an annual basis.
Attachment #20.6 |
12/02/2022
| Implemented |
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