| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment for the home. The home's certificate of compliance has expiration date 1/9/18. | 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.
| Persons Responsible-
Executive Director & Assistant Director
Action-NF, will ensure 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. Protocol-Executive Team created an annual checklist that covers all important task according 6400 regulations that will also cover the agency¿s self-assessments to ensure all areas are not missed.
All system should be in place be 3/9.
Compliance Officer will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team.
Next inspection will be 3/9/2018.
[Prior to 3 months of expiration of Certificate of Compliance, the Executive Director or designee shall review all self assessments of each home to ensure timely completion. (AS 2/22/18)] |
03/09/2018
| Implemented |
| 6400.46(c) | Chief Executive Officer #1, date of hire 4/20/15, did not have 24 hours of training relevant to human services or administration. There were no records documenting Chief Executive Officer #1's amount of training within the training year of 7/1/16 to 6/30/17. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Persons Responsible-
Executive Director & Assistant Director
Action-(1)In moving forward, Not Forgotten will ensure the chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. (2)Not Forgotten has revamped the training program and policy procedures to ensure the 24 hours training in implemented in a timely fashion.
Protocol-Executive Team created an annual checklist that covers the chief executive officer shall have at least 24 hours of training relevant to human services or administration annually to ensure all areas are not missed.
All system should be in place be 3/9.
Compliance Officer will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team.Next inspection will be 3/9/2018.
3/9/2018 Corrected [Documentation of quarterly checks by the compliance officer shall be kept and reviewed by the Executive Director for at least 1 year. (AS 2/22/18)] |
03/09/2018
| Implemented |
| 6400.68(b) | The hot water temperature measured 129.3 °F in the bathtub in the attached bathroom of bedroom #1 at 10:10am on 12/28/17. (Repeated Violation-1/9/17, et al) | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Person Responsible-Maintenance FacilitatorAction-1) Not Forgotten has adjusted hot water temperatures in bathtubs and showers may not exceed 120°F. (2) Not Forgotten has hired a maintenance facilitator to ensure they are being monitored. (3) Not Forgotten will monitor weekly the temperatures with a weekly tracking sheet.
Protocol-Residential staff will perform a weekly check to make sure of water temperatures in bathtubs and showers may not exceed 120°. MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.Next inspection will be 3/9/2018.Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [Immediately, the Executive Director shall train all staff person responsible for ensuring the hot water temperatures at bathtubs and showers does not exceed 120 degrees of their responsibilities. Documentation of the trainings shall be kept. (AS 2/2/18)] |
03/09/2018
| Implemented |
| 6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in living room area. | 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.
| Persons Responsible-
Program Specialist & Program Coordinator
Action-Not Forgotten has placed 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.
Protocol-Program Specialist and Program Coordinator will create checklist to make sure 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 according to regulations are covered. All system should be in place be 3/9. Assistant Director will perform a quarterly inspection to make Not Forgotten is in compliance and will report issues and concerns to the quality management team. Next inspection will be 3/9/2018. [Immediately, the Executive Director shall train all staff persons of the telephone numbers required by all telephones and to use if needed and monitor throughout the course of their daily duties. (AS 2/22/18)] |
03/09/2018
| Implemented |
| 6400.110(b) | The closest smoke detector to bedroom #2 on the left side of the apartment was 16.5 feet from the bedroom door. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | Person Responsible-
Maintenance Facilitator
Action-Smoke was installed to bedroom #2 on the left side of the apartment was 16.5 feet from the bedroom door.
Protocol-Maintenance Facilitator will perform a quarterly check to make sure there¿s a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
MF will perform a quarterly inspection of all physical facility and will record finding on a checklist. If problems exist, MF will notify his direct supervision of any problems and will immediately fixed the problem.
Next inspection will be 3/9/2018.
Not Forgotten Staff working in the home shall notify MF if there¿s a missing smoke detector and/or inoperable smoke detector. MF will follow protocol of immediately replacing, fixing or installing smoke detector(s). [Immediately, the Maintenance facilitator shall install a smoke detector within 15 feet of bedroom #2 in the common area or hallway. Immediately and upon opening new homes and at least semi-annually, designated management staff person and the maintenance facilitator shall completed an onsite check of all community homes to ensure there is an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Documentation of onsite checks shall be kept. (AS 3/8/18)] |
03/09/2018
| Implemented |
| 6400.151(a) | Direct Service Worker #2, date of hire 2/4/17, did not have a physical examination. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Persons Responsible-Nurse Coordinator Action-Not Forgotten updated the orientation policy and procedure to ensure the staff are turning in their physical examination prior to employment. Protocol-Nurse will create a medical checklist for new staff working under chapter 6400 who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Nurse will check that staff completes a yearly physical. All system should be in place be 3/9.
Compliance Officer will perform a quarterly inspection of nurse¿s documentation to make sure Not Forgotten is in compliance and will report issues and concerns to the quality management team. Next inspection will be 3/9/2018. [Immediately, Direct Service Worker #2 will cease working in community homes until physical examination is completed and documentation is maintained at the agency. Immediately, upon completion and at least quarterly, a designated management staff person and the nurse shall audit all staff persons' current physical examination and the aforementioned tracking checklist to ensure completion of physical examinations, timely. Documentation of the audits shall be kept. (AS 3/8/18)] |
03/09/2018
| Implemented |