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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | Request for padded wall repair made 11/4/22-however the condition of the wall was more than a week's worth of damage from head banging. The wall is peeling, minimal padding. | 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 11/4/22 to repair the padded wall. This was resolved 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 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 and 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 #22 |
12/30/2022
| Implemented |
| 6400.110(e) | Smoke detectors in home are not interconnected-licensed 2/27/14. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | What was done immediately to correct the specific issue cited?
Building Supervisor in the Real Estate Division of Horizon House, contracted with Chalmers Security System, Inc. to assess and install interconnected smoke detectors.
What specific change will be made?
Installation of interconnected smoke detectors to occur on or by 2/3/2023 inclusive of demonstration and instruction on use with assigned Site Supervisor. There will also be an evaluation of the residential sites to ensure that all residential sites are 3 or more stories (including attic and basement) have interconnected smoke detectors.
Who (by title) will make the change?
William Williams, Building Supervisor, will ensure that Contracted Installer, Chalmers Security System, completes the work.
When will the change be made?
Installation shall occur on or by 2/3/2023.
What system has been implemented to make sure the same violation does not occur again?
All DS residential sites that are 3 or more stories (including attic and basement) will be assessed to determine if all the smoke detectors are interconnected. Any site that is not interconnected, a work order will be submitted immediately to have it resolved.
What education and training has been provided to staff?
Staff were educated on the importance of having interconnected smoke detectors at any site that has 3 or more stories (including attic and basement). They were also advised to report to management staff if there are any issues with interconnected smoke detectors.
Attachment #22.2 |
02/03/2023
| Implemented |
| 6400.32(i) | No clothes found in Matthew Hibbs' closet or dresser drawers-they were housed in the basement. Staff states furniture was delivered Sunday. Bins of clothes replaced during inspection. | 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?¿¿
On 11/16/2022 the clothing for Participant MH was moved and put away in the new dresser delivered as well as the bedroom closets.
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What specific change will be made?¿
Clothing for Participants is to be placed in clothing appropriate spaces in the Participant's bedroom. Should there be a concern or reason to believe this placement is not appropriate, the Program Specialist and Program Managers are responsible to 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¿
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When will the change be made?¿
Change was effective on 11/16/2022.
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What system has been implemented to make sure the same violation does not occur again?¿
Site Supervisor is responsible to ensure Participant clothing is placed appropriately in dressers and/or closets. Should this not be feasible, it is the Site Supervisors responsible to ensure that is communicated to the Program Director. 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 to reflect the reasoning the clothing cannot be placed in these appropriate areas. 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 #22.1 |
11/16/2022
| Implemented |
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