6400.15(a) | The agency did not fully complete the self-assessment, dated 1/18/19; regulations 6400.44(b)(4) through 6400.46(j) were not addressed. | 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.
| Our corrective action will be to complete a full self assessment for each home in January of every year. Which is 6 months prior to our licensing. Our compliance officer Alice Taylor is responsible for completing each assessment CEO will review each self assessment to ensure any items not in compliance are addressed prior to licensing. [Upon completion and prior to 3 months of the expiration of the certificate of compliance, the CEO shall audit all self assessments for all community homes to ensure all regulations are measured for compliance and documented accurately. Documentation of the audits by the CEO shall be kept. Prior to completion, the CEO shall train all staff persons responsible for completing self assessments, on the regulations and the procedures for documenting the measurement and recording compliance. Documentation of the training shall be kept. (DPOC by AES,HSLS on 8/1/19)] |
07/15/2019
| Implemented |