| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The home's self-assessment, completed on 2/14/23. The agency certificate of compliance expires 10/18/23 and the last renewal inspection was completed 4/27/22. | 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.
| A self-assessment will be completed at least annually within the 3¿6-month time frame set forth in the 6400 regulations. The Self-Assessment Forms will be prepared by the Program Manager annually in April and are then scheduled to be completed in a timely manner to allow for corrections to be made and follow-up inspections to occur within the time frames. |
04/28/2023
| Implemented |
| 6400.66 | On 4/7/23, the light fixture outside of the dining room side door was found inoperable at 2:08 PM. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The Maintenance Supervisor checked the lightbulb in the fixture and found that a lightbulb made for a dimming switch was required. The correct type of lightbulb was placed in the light fixture which is now operable on 04/20/2023. |
04/20/2023
| Implemented |
| 6400.111(f) | On 4/7/23, the fire extinguishers located on the main level in the kitchen and in the basement of the home were last serviced by a fire safety expert in March 2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher was re-serviced and inspected on 04/21/2023 by ABC Fire Company. |
04/21/2023
| Implemented |
| 6400.18(a)(3) | EIM Incident # 9135219 for a behavioral health crisis involving psychiatric hospitalization was discovered on 12/11/22 at 8:56 AM and reported on 12/12/22 at 2:42 PM. EIM Incident # 9170360 for a serious illness involving hospitalization was discovered on 2/15/23 and reported on 2/19/23. EIM Incident # 9142555 for a serious illness involving hospitalization was discovered on 12/25/22 and reported on 12/28/22. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital.
| The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Inpatient admission to a hospital within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(4) | EIM Incident # 9153014 for abuse was discovered on 1/17/23 at 10:59 AM and reported on 1/18/23 at 12:35 PM. EIM Incident # 9180095 for abuse was discovered on 3/8/23 at 8:50 AM and reported on 3/9/23 at 12:29 PM. EIM Incident # 9100063 for individual-to-individual abuse was discovered on 10/3/22 at 5:36 PM and reported on 10/4/22 at 9:50 PM. EIM Incident # 9179271 for abuse was discovered on 3/6/23 at 12:00 AM and reported on 3/7/23 at 7:35 PM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Abuse, including abuse to an individual by another client within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(5) | EIM Incident # 9108975 for neglect was discovered on 10/15/22 and reported on 10/21/22. EIM Incident # 9110331 for neglect was discovered on 10/14/22 and reported on 10/24/22. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Neglect within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(6) | EIM Incident # 9158262 for exploitation was discovered on 1/21/23 and reported on 1/26/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Exploitation
. | The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Exploitation within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(8) | EIM Incident # 9162831 for a behavioral health crisis involving law enforcement was discovered on 2/3/23 at 10:30 AM and reported on 2/4/23 at 11:18 AM. EIM Incident # 9156648 for a behavioral health crisis involving law enforcement was discovered on 1/21/23 and reported on 1/24/23. EIM Incident # 9155392 for law enforcement activity involving an individual charged with a crime was discovered on 1/19/23 and reported on 2/10/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Law enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual.
| The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Law Enforcement activity that occurs during the provision of a service or for which an individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(11) | EIM Incident # 9156780 for a site closure was discovered on 1/21/23 and reported on 1/24/23. EIM Incident # 9153476 for a site closure was discovered on 1/14/23 and reported on 1/18/23. EIM Incident # 9151991 for a site closure was discovered on 12/26/22 and reported on 1/15/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Emergency closure.
| The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report Emergency closure within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(a)(13) | EIM Incident # 9150242 for a rights violation was discovered on 12/9/22 and reported on 1/13/23. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
A violation of individual rights. | The Quality Assurance Director will retrain all staff including Point Persons on reporting timelines and the Agency Incident Management policy, emphasizing the requirement to report a violation of individual rights within 24 hours of discovery. |
05/31/2023
| Implemented |
| 6400.18(g) | EIM Incident # 9177557 for neglect was discovered on 3/1/23, and a certified investigation was started on 3/3/23. EIM Incident # 9108975 for neglect was discovered on 10/15/22, and a certified investigation was started on 10/21/22. EIM Incident # 9110331 for neglect was discovered on 10/14/22, and a certified investigation was started on 10/26/22. EIM Incident # 9158262 for exploitation was discovered on 1/21/23, and a certified investigation was started on 1/27/23. EIM Incident # 9179271 for abuse was discovered on 3/6/23, and a certified investigation was started on 3/8/23. EIM Incident # 9150242 for a rights violation was discovered on 12/9/22, and a certified investigation was started on 1/12/23. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | The Quality Assurance Director will re-train all Point Persons and Certified Investigators on reporting and investigation timelines and the Agency Incident Management policy, emphasizing the requirement to initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. |
05/31/2023
| Implemented |