| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | REPEAT VIOLATION FROM 12/10/19: The self-assessment for this home is dated 8/7/20, which is outside of the required time frame. The self-assessment is also incomplete. | 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 is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/findings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. |
03/05/2021
| Implemented |
| 6400.71 | At the time of inspection, the telephone in the home did not have emergency numbers on or near it. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| This is important to ensure that the staff and persons in care always have the emergency numbers easy accessible in the event they are needed The numbers were posted by but not directly on the cordless phone The change in leadership turnover resulted in an oversight of this requirement. A label maker will be purchased so that the numbers can be posted on the cordless phone . The program mangers will be notified of this regulation and will be tasked with the understanding that the numbers must remain on the phone and reposted as needed The Director of Compliance and the Residential Directors will meet semi-annually in June and November to review the phones in the residence is labeled with the emergency numbers. Any necessary corrections will be completed at that time |
03/05/2021
| Implemented |
| 6400.103 | There are no written emergency evacuation procedures for the home. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Ensure a calm transition and the safety of people in care in an emergency situation Plans used in the past were found to be inadequate There has been an increased rate of staff and leadership turnover Directors will review the regulation and develop an evacuation template plan that is sufficient for all residents. The Program Managers and Associate Director of Services will tailor to their specific locations. The Director of Compliance and the Residential Directors will meet semi-annually in June and November to review the evacuation plans for the residences. Any necessary corrections will be completed at that time |
03/12/2021
| Implemented |
| 6400.106 | The furnace was cleaned and inspected on 9/23/19 and not again until 10/10/20. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| This regulation is important to identify any dirty, malfunctioning or defective parts that could lead to unsafe air or a fire. The inspection and cleaning service was not done within the 365 day regulation timeframe. For the safety of the people we support and staff, TLC kept all unnecessary repairs and personnel from entering the homes whenever possible during COVID. Furnace inspections were delayed as long as possible in hopes that COVID would be over. This concern/effort caused the 365 day regulation to be missed. The furnace was inspected and cleaned on 10/10/2020 by Regal Inc. Reestablish the normal cleaning scheduling process for the 2021/22 furnace inspection season. The Director of Properties and Purchasing will work with the inspection company to meet the 365 day regulation. |
03/19/2021
| Implemented |
| 6400.112(c) | The fire drill record from 12/1/2019 through 12/31/2020 did not include the day the drill was completed, problems encountered, and whether or not the smoke detectors were operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. The fire drill record was incomplete. The change in leadership turnover resulted in an oversight of this requirement. Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.112(e) | There were no fire drills conducted during sleeping hours between 12/1/2019 and 12/31/2020. | A fire drill shall be held during sleeping hours at least every 6 months. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. Sleep fire drills were not conducted for the 12/2019-12/2020 time period The change in leadership turnover resulted in an oversight of this requirement. Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Implemented |
| 6400.112(h) | The fire drill record from 12/1/2019 through 12/31/2020 did not indicate if all individuals evacuated to a designated meeting place for each fire drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. Individuals did not make it to the designated location. Various staff and supervisor changes led to inconsistencies within quality of training received and comprehension of regulations Fire Drills are now input and monitored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. |
03/12/2021
| Not Implemented |
| 6400.32(r) | Individuals #1, 2, and 3 were not offered the option to lock their bedroom doors. | An individual has the right to lock the individual's bedroom door. | Individuals have the right to have locks on their bedroom doors to protect their belongings. Individuals were not offered the opportunity to have locks placed on their bedroom doors. The choice to have a lock on a bedroom door was not discussed during team meetings. The residential provider will contact the individual's team to schedule a meeting to discuss the person's choice for a lock on the bedroom door. If the person wants a lock, the residential provider will ensure a lock is installed. The meetings will take place by 4/30/2021 and be scheduled by the Clinical ADOS before March 10 During the annual ISP meeting, or when the person requests, the residential provider will ensure the subject of securing the bedroom is discussed. The Directors of Residential will monitor the completion of this task during monthly supervisions with the residential Clinical and Operational Associate Directors. |
03/12/2021
| Implemented |