| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022. | 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.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.15(c) | The agency did not utilize the comment boxes to capture identified violations, or a summary of corrections made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. |
03/01/2023
| Implemented |
| 6400.64(f) | The outdoor trash receptacle located near the front entrance of the home was overfilled approximately seven inches with garbage, rendering the lid unable to be closed. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Additional trash receptacle was added to the home 1/3/23 in order to prevent future violation. House manager instructed to monitor weekly for compliance and to alert CEO if there are any issues identified. Staff to be reminded of importance of maintaining outdoor trash receptacles and trained on applicable regulatory requirements. |
03/01/2023
| Implemented |
| 6400.67(a) | A two feet long by one and a half feet section of the floor, abutting the bathtub in the bathroom, was soft and spongy and receded when stepped on, due to apparent water damage; posing falling risk. | Floors, walls, ceilings and other surfaces shall be in good repair. | Incident report for site closure was submitted into HCSIS as bathroom was remodeled over three days and is the only bathroom for the house. Floor, walls bathtub and surround all renovated. New subfloor, flooring was installed. Renovations were completed on 12/12/23 and site reopened. Individual returned home and maintained typical scheduled programming and daily activities during the closure. |
03/01/2023
| Implemented |
| 6400.171 | On 11/30/2022. a carton of eggs with an expiration date of 11/28/2022 was in the refrigerator in the kitchen of the home. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Discarded at time of inspection. CEO will post reminder at all houses that all staff are required to monitor the refrigerator and freezer and all foods in cabinets for dates on stored and prepared foods to ensure any items that are near an expiration date are discarded according to expiration date. House managers will be responsible for maintaining monthly checklist that checks are being done on a regular basis. CEO and program specialist to conduct site monitoring monthly. |
03/01/2023
| Implemented |
| 6400.18(a)(11) | On 11/30/2022, Chief Executive Officer #1 stated that Individual #1 was recently located to a hotel for a few days due to the heating oil being too low in the home. This incident was not reported into the Department's information management system. | 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.
| All incidents will be reported into HCSIS and will be done so according to the regulatory requirements. Administration responsible for reporting incidents will ensure that site closures are reported timely. |
03/01/2023
| Implemented |