| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | Futures Individual Finance Policy last revised on 4/6/20 indicates that each individual shall "maintain a maximum of $100.00 at their home, unless specified differently in their individual support plan. However, an individual may retain more than the maximum amount if deemed necessary by the program specialist, frontline supervisor and the individual." "Any amount in excess of $250.00 should be spent as soon as possible so excessive amounts are not on hand, or individual's benefits are not affected. Also noted in the policy is "A minimum amount of cash on hand for each person and from agency household money will be accessible to staff each day. For most individuals, this amount will not be more than $25.00 dollars. The remaining money in the house will be placed in a lock box which will be maintained in a secured location. This box will be accessible to only the frontline supervisor or the program specialist." During a review of individual finances for Individual #1 it was discovered that the established financial policy was not being followed as written. Client finance reports illustrated that amounts in the "Lock Box" greatly exceeded outlined amounts during the months reviewed. On 2/1/22 there was a balance of $1,298.29, on 3/1/22 a balance of $1,178.28, on 4/1/22 a balance of $1,178.28, on 5/1/22 a balance of $850.23, on 6/1/22 a balance of $1,850, on 7/1/22 a balance of $1,400 in the "lock box" belonging to Individual #1 located in the home. Futures must follow policies established by the agency. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | Futures Individual Finance Policy 200.6 has been updated. Current direct support professionals, frontline supervisors, and program specialist Staff will read and acknowledge this by 9/4/22. In addition, frontline supervisors, and program specialists will review the updates in the policy and the reasons why during a staff meeting by 9/30/22. |
09/30/2022
| Implemented |
| 6400.22(e)(3) | June 2022 Client Finance Report for Individual #1 contains an entry for the purchase of an Amazon gift card in the amount of $400. A Lost Receipt Form was completed by Staff #8 on 8/4/22. Receipts for purchases made with the Amazon gift card were requested and not produced. Gift and credit cards are to be treated as financial resources belonging to the individual. Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person shall be maintained. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The Amazon gift card is part of an active investigation (incident # 9066532) as it was stolen along with cash. Receipts were taken when the gift card and cash were stolen. |
09/09/2022
| Implemented |
| 6400.62(a) | Assessment for Individual #1 dated 11/15/21 indicates that Individual #1 would be at risk of ingesting poisons/cleaning supplies. At time the of inspection, Saniflex and bleach were found under the sink in the main bathroom used by Individual #1. A partially used bottle of antifreeze was found in the parking area of the home next to the site vehicle. Pine Sol liquid cleaner as well as Easy Off oven cleaner were located under the kitchen sink. All labels indicated that poison control should be notified, or medical attention sought if the chemicals were ingested. All areas were unlocked and poisons easily accessible to Individual #1. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The poisonous substances have been locked up and the empty container of anti-freeze that was outside has been thrown away. Program specialist and frontline supervisor addressed at the staff meeting on 8/11/22. |
08/11/2022
| Implemented |
| 6400.64(a) | At time of inspection the kitchen was noted to have several unsanitary areas. The base of the Ninja food processor used daily to prepare meals was caked with dried food. The coffee maker was soiled with what appeared to be dried coffee spills and a greasy film, the bottom surface of the cabinet where the cookie sheets were stored was covered with what appeared to be dust and dried food particles, the cabinet that stored the cookware for the home was also found to be soiled with what appeared to be dust and food particles. The basement of the home was cluttered with boxes, used furniture and equipment, incontinence supplies and various other discarded and stored items. The basement is not accessible to the Individuals, but clean and sanitary conditions shall be maintained in all licensed areas. | Clean and sanitary conditions shall be maintained in the home. | Program specialist updated their cleaning checklist that is completed by direct support professionals and reviewed with them on 8/11/22. Program specialist and frontline supervisor will remove items in the kitchen that are no longer used therefore collecting dust.
Maintenance will remove items from the basement that are no longer functioning or in working condition. Any items that remain in the basement will be organized.
Program specialist will replace the coffee urn that was cloudy due to age.
Staff will clean appliances after use as long as it does not interfere with individual care and needs.
Small appliances will be replaced when needed. |
10/14/2022
| Implemented |
| 6400.64(b) | At time of inspection approximately 15-20 mouse droppings were noted under the kitchen sink. | There may not be evidence of infestation of insects or rodents in the home. | CEO contacted Terminex who visited the site on 8/26/22 in effort to address the mice in the home. Until th mice have been removed staff will clean up droppings. |
08/29/2022
| Implemented |
| 6400.67(a) | The shower base in the main area of the home was heavily stained with what appeared to be a rust-colored substance.
The tile floor on the sunporch located off the bedroom of Individual #1 was missing two tiles. Missing tiles were approximately 10" x 10."
The threshold under the basement door on the left leading outside was loose, there was no threshold under the basement door leading to the outside on the right leaving an open crack between the bottom of the door and the surface of the floor. The screen door located on the van parking are did not have an upper glass or screen, this area is completely open on two sides.
The painted kitchen cabinet doors of the home had multiple areas where the paint was worn off.
The deck stairs and wooden handrail leading from the outside of Individual #1's bedroom to the back yard area of the home was very loose and unstable. These stairs are not used by the individuals due to physical limitations. | Floors, walls, ceilings and other surfaces shall be in good repair. | The shower will be replaced. |
10/31/2022
| Implemented |
| 6400.110(a) | At time of inspection the detector in the attic did not alert. There was no noise emitted from the detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The detector in the attic is a heat detector. Correspondence with Chris Hadley indicates that this is acceptable. Documentation was sent to Chris from Select Security. |
08/30/2022
| Implemented |
| 6400.142(e) | Individual #1 had an annual dental visit on 10/8/21. It was recommended that "rest of teeth to be extracted." There was no documentation to support that this had been completed nor was there documentation provided to show that the extraction was in the process of being completed or scheduled. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | Program specialist had contacted Individual #1's brother after this appointment to discuss the recommendations. Individual #1's brother, next of kin, who would need to consent for the procedure was not in support of her teeth being removed. This conversation was not documented nor was anything obtained in writing from her brother. Program specialist will follow up with brother again to verify his decision and document. |
09/09/2022
| Implemented |
| 6400.144 | Individual #1 had an annual dental visit on 10/8/21. Under "Frequency" it was noted there was a "6 MRC" or 6-month recall. Documentation for dental visits after the 10/8/21 were requested with Staff #7 responding that "Due annually therefore would be due on 10/22." Doctor recommendation would indicate that a return visit had been due in April 2022. This was not completed. It was recommended at the 10/8/21 dental that "Rec. use kids size tb to reach up around teeth better." At the time of inspection only an adult size toothbrush was in use for Individual #1. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The 6 month exam was cancelled by Canton Dental because they no longer accepted her insurance which resulted in the frontline supervisor and program specialist to locate a dentist that accepted her insurance and was accepting new patience. Individual #1 has a dental exam scheduled 2/9/23 as this was soonest appointment available with Ollock Dentai Group. |
08/29/2022
| Implemented |