|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was completed on 7-15-2016, and the certificate of compliance expired on 2-5-2017. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The Residential Program Coordinators were all re-trained on the Plan of Correction for the 6400 audit. The Program Director will generate a reminder for all Self-Assessments to be completed when we are six months from the expiration of our current license, which is due to expire on 02/05/2018. The reminder will be sent by email.[Prior to 3 months of the expiration date of the agency's certificate of compliance, the Program Director shall review all self-assessments to ensure timely completion. Documentation of the review shall be kept.(AS 3/10/17)] |
03/06/2017
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" form, signed by Individual #1 on January 1, 2014, did not include the right to privacy per 6400.33(e) -- that "an individual has the right to privacy in bedrooms, bathrooms and during personal care." | (b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept.
| The Director of the Residential Services, updated the Individual Rights Acknowledgement form. Once the form was updated to include the 31(b), all Program Coordinators were trained on the change and new forms were reviewed and signed by ALL individuals. In additon to the Program Coordiators, all Residential staff were also trainined on the basics of the 6400 regulations and the most recent updates from this audit. |
02/25/2014
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not denote the language spoken by the individual. | Each individual's record must include the following information:
(1) Personal information including:
(i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| The Director of the Residential Services, trainined ALL Program Coordinators to include the individuals primary language on the Individual Information Summary. The individuals records were updated to include the primary language. In additon to the Program Coordiators being trainined all Residential staff were also trainined on the basics of the 6400 regulations and the most recent updates for this audit. |
02/25/2014
| Implemented |
|
|