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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | There was a fish tank in the bedroom of individual #1, who is currently not living in the home. The tank was half full and had the appearance of a black substance consistent with mold throughout. | Clean and sanitary conditions shall be maintained in the home. | Correction ¿ Immediate Cure
WHO:
Elvira Berry, Executive Director
Barry Baruwa, Program Specialist
Al Williams, House Manager
NaeEmah Johnson, Office Manager
WHAT:
We need to ensure that the fish tank is clean, thus ensuring clean and sanitary conditions are maintained in the home.
HOW:
1. We cleaned the fish tank on September 20, 2019, and removed the fish tank with the Consumer¿s permission on November 21, 2019.
2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager.
3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day.
4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day.
5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019.
6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019.
7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019.
8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man.
Correction Activity ¿ Prevention of Reoccurrence
We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home. We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. |
12/26/2019
| Implemented |
6400.66 | The light by the back door of the home in the basement had a broken bulb left in the fixture. Staff was unable to remove the bulb to install a new one. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Correction ¿ Immediate Cure
WHO:
Elvira Berry, Executive Director
Barry Baruwa, Program Specialist
Al Williams, House Manager
NaeEmah Johnson, Office Manager
WHAT:
We need to ensure that there is sufficient lighting in the home, which includes rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes. This will involve changing the way in which we currently conduct our weekly home inspections.
HOW:
1. We fixed the light fixture on September 20, 2019.
2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager.
3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day.
4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day.
5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019.
6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019.
7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019.
8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man.
Correction Activity ¿ Prevention of Reoccurrence
We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home.
We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. |
12/26/2019
| Implemented |
6400.67(b) | The dryer vent in the basement was disconnected from the wall and leaning against an interior wall. The hole left from the vent was open.
There was a pile of clothing in back of the dryer consisting of approximately 8 items. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Correction ¿ Immediate Cure
WHO:
Elvira Berry, Executive Director
Barry Baruwa, Program Specialist
Al Williams, House Manager
NaeEmah Johnson, Office Manager
WHAT:
We need to ensure that all floors, walls, ceilings and other surfaces are free of hazards.
HOW:
1. We fixed the dryer on September 20, 2019.
2. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager.
3. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day.
4. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day.
5. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019.
6. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019.
7. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019.
8. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man.
Correction Activity ¿ Prevention of Reoccurrence
We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home.
We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. |
12/26/2019
| Implemented |
6400.104 | The notification letter to the fire department dated 2/4/19 did not include exact location of individuals bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Rachael Cohen, Compliance Specialist
WHAT:
We need to ensure that the notification to the fire department contains information related to the exact location of each Individual¿s bedroom.
WHEN:
Fire Department Notification Policy ¿ September 23, 2019
Fire Department Notification Policy training for the Compliance Specialist ¿ September 25, 2019
Fire Department Notification Policy training for the Program Specialist ¿ September 25, 2019
New Notifications Sent to Fire Department ¿ September 20, 2019 to November 20, 2019
HOW:
We drafted a Fire Department Notification Policy and conducted training on the policy. We also re-sent the letters to the fire department.
Correction Activity ¿ Prevention of Reoccurrence
The policy was initially part of the admission process and assigned to the Program Specialist. We created a separate Fire Department Notification policy and assigned the task to the Program Specialist and Compliance Specialist. In the policy, there are sample letters to send for notification. |
11/20/2019
| Implemented |
6400.105 | There was a gas lawn mower stored in the basement of the house, and had gasoline in the mower. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Correction ¿ Immediate Cure
WHO:
Elvira Berry, Executive Director
Barry Baruwa, Program Specialist
Al Williams, House Manager
NaeEmah Johnson, Office Manager
All Staff
WHAT:
We need to ensure to flammable and combustible supplies and equipment are utilized safely and stored away from heat sources.
HOW:
1. We removed the lawn mower from the basement on September 20, 2019.
2. We drafted the flammable and Combustible Supplies policy on September 30, 2019.
3. Staff was trained on the Flammable and Combustible Supplies Policy on November 21 and 22, 2019, then again from December 23 to 25, 2019.
4. Weekly Site Inspection ¿ a weekly site inspection will be conducted by Mr. Al Williams, House Manager.
5. Weekly Site Inspection Frequency ¿ There are five sites and five weekdays. Therefore, Mr. Williams will inspect one site per day.
6. Weekly Site Inspection Checklist Training ¿ Mr. Williams was trained by Elvira Berry on November 27, 2019. The training was conducted at the sites during the site training which occurred on the same day.
7. Maintenance Hotline Training, Residential ¿ During a weekly site inspection, Mr. Williams is required to call the maintenance hotline to report any maintenance related issues. Mr. Williams was trained on the Maintenance Hotline on November 28, 2019.
8. Maintenance Hotline Training, Office- The Office Manager, NaeEmah Johnson, receives an email when the maintenance hotline is called. Ms. Johnson was trained on the hotline on October 21, 2019. She was re-trained again by Elvira Berry on November 22, 2019, and again on December 19, 2019.
9. Weekly Site Inspection Audit ¿ Mr. Barry Baruwa, Program Specialist, will conduct site audit of two random homes every week, with all the homes being audited at least once per month. Mr. Baruwa was trained on the Weekly Site Inspection on November 27, 2019 and December 19, 2019.
10. Home Compliance ¿ Each home was inspected this week by three people: by Mr. Williams on December 23 and 24, 2019, by Mr. Baruwa on December 25 and 26, 2019, and by Ms. Berry on December 23 and 26, 2019. All maintenance needs were forwarded to Ms. Berry, who personally assigned the maintenance tasks to the maintenance man.
Correction Activity ¿ Prevention of Reoccurrence
We hired a new house manager who has extensive experience in 6400 regulatory compliance. He was highly recommended by two different sources. In addition, this House Manager was trained by the Executive Director in 6400 Regulations, with each training occurring by going to each house, and discussing the nuances of each home.
We also made the Weekly Home Inspection Checklist a required discussion item for Thursday Round Ups. Thursday Round Ups is a fast meeting we have on Thursdays to discuss the week¿s progress, problems, needs, etc. |
12/26/2019
| Implemented |
6400.112(c) | The fire drill for September 2018 did not include if the smoke detector was operable, it was left blank. | 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. | Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Tanya Carter, House Manager
WHAT:
We need to ensure that Fire Drill form is fully completed so that it indicates whether the smoke detector was operable at the time the fire drill was conducted.
WHEN:
Fire Drill Policy Updated¿ September 23, 2019
Fire Drill Policy training for Program Specialist ¿ September 24, 2019
Fire Drill Policy training for House Manager ¿ October 29, 2019
HOW:
The Fire Drill Policy was updated, and a training was conducted for the Program Specialist and House Manager on September 24, 2019 and October 29, 2019.
Correction Activity ¿ Prevention of Reoccurrence
We changed the assignee for the task by updating the assignee section of the Fire Drill Policy. Rather than the task being completed by the staff, then reviewed by the House Manager, the task can only be completed by the House Manager, then reviewed by the Program Specialist. This will ensure that all the sections are completed during the fire drill. |
10/29/2019
| Implemented |
6400.112(e) | The time of day ( AM/PM) was not indicated on some of the fire drills, it could not be determined if sleep drills were held. | A fire drill shall be held during sleeping hours at least every 6 months. | Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Tanya Carter, House Manager
WHAT:
We need to ensure that there is a clear indication on the Fire Drill form of when the fire drill was conducted, so that we know whether we are in compliance with the requirement to have at least one fire drill during sleeping hours.
WHEN:
Fire Drill Form Updated ¿ September 23, 2019
Fire Drill Form training for Program Specialist ¿ September 24, 2019
Fire Drill Form training for House Manager ¿ October 29, 2019
HOW:
The Fire Drill form was updated, and a training was conducted for the Program Specialist and House Manager on September 24, 2019 and October 29, 2019.
Correction Activity ¿ Prevention of Reoccurrence
We changed our Fire Drill form to have a mandatory option to check off for AM/PM instead of leaving the option of providing the information up to staff. We also changed the assignee for the task. Rather than the task being completed by the staff, then reviewed by the House Manager, the task can only be completed by the House Manager, then reviewed by the Program Specialist. |
10/29/2019
| Implemented |
6400.141(c)(6) | The last tuberculin test was completed on 4/24/17 for individual #1. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Iris West, Nurse
Tanya Carter, House Manager
WHAT:
We need to ensure that each Individual has Tuberculin skin testing by Mantoux method with negative results every 2.
WHEN:
Updated Appointment Policy ¿ October 15, 2019
New TB testing for Individual 1 ¿ October 24, 2019
Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019
HOW:
The Program Specialist took Individual 1 for TB testing on October 24, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy.
Correction Activity ¿ Prevention of Reoccurrence
We updated our appointment policy so that the appointment timeline is clearer. This ensures that appointments are timely. |
10/29/2019
| Implemented |
6400.141(c)(11) | Health maintenance needs were not addressed in the physical dated 5/2/19 for individual #1. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Iris West, Nurse
Tanya Carter, House Manager
WHAT:
We need to ensure that each Individual¿s physical is fully completed so that there is a list of recommendations for health maintenance, medication regimen and the need for blood work at recommended intervals.
WHEN:
Updated Appointment Policy ¿ October 15, 2019
Physical Form review by Nurse ¿ October 21, 2019
Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019
Physical Form re-training for Program Specialist ¿ November 13, 2019
Physical Form training for House Manager ¿ November 13, 2019
New physical for Individual 1 ¿ November 20, 2019
HOW:
The Nurse reviewed the physical form, then trained the Program Specialist and House Manager on the form. Individual 1 has an appointment for a new physical on November 20, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy.
Correction Activity ¿ Prevention of Reoccurrence
We updated our appointment policy so that staff can no longer attend annual appointments such as physicals alone. In the updated policy, a staff must be accompanied by the Nurse, Program Specialist or House Manager for physicals. This ensures that the physical form is reviewed for accuracy before the Individual leaves the doctor¿s office. |
11/22/2019
| Implemented |
6400.141(c)(14) | Information pertinent to diagnosis in case of emergency was left blank on the physical form dated 5/2/19 for individual #1. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Iris West, Nurse
Tanya Carter, House Manager
WHAT:
We need to ensure that each Individual¿s physical is fully completed so that it indicates the medical information pertinent to diagnosis and treatment in case of an emergency.
WHEN:
Updated Appointment Policy ¿ October 15, 2019
Physical Form review by Nurse ¿ October 21, 2019
Training on Updated Appointment Policy (House Manager, Nurse and Programs Specialist) October 29, 2019
Physical Form re-training for Program Specialist ¿ November 13, 2019
Physical Form training for House Manager ¿ November 13, 2019
New physical for Individual 1 ¿ November 20, 2019
HOW:
The Nurse reviewed the physical form, then trained the Program Specialist and House Manager on the form. Individual 1 is scheduled for another physical on November 20, 2019. The Nurse, Program Specialist and House Manager were trained on the new appointment policy.
Correction Activity ¿ Prevention of Reoccurrence
We updated our appointment policy so that staff can no longer attend annual appointments such as physicals alone. In the updated policy, a staff must be accompanied by the Nurse, Program Specialist or House Manager for physicals. This ensures that the physical form is reviewed for accuracy before the Individual leaves the doctor¿s office. |
11/22/2019
| Implemented |
6400.144 | Individual #2's medication, Polyeth Powder was not available at the time of this inspection. Staff signed for the 8am dose. The inspection took place at 9:30. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Correction ¿ Immediate Cure
WHO:
Adekunle Baruwa, Program Specialist
Tanya Carter, House Manager
All Staff
WHAT:
We need to ensure that there is an adequate system for accurately accounting for each medication so that it is clear that the needed medical, nursing, pharmaceutical, dental, dietary and psychological services are arranged for and/or provided.
WHEN:
Medication Administration Policy/Checklist Updated ¿ September 23, 2019
Medication Administration Policy/Checklist training for Program Specialist¿ September 24, 2019
Medication Administration Policy/Checklist training for House Manager¿ October 29, 2019
Medication Administration Policy/Checklist training for Staff¿ November 21 and 22, 2019
HOW:
We updated the Medication Administration Policy/Checklist, and trained the Program Specialist and House Manager on the new policy. Staff will be trained by November 22, 2019.
Correction Activity ¿ Prevention of Reoccurrence
We updated our Medication Administration Policy/Checklist to ensure that the mediation administration process is clearer. We posted the revised Medication Administration Policy/Checklist at each home, above the table on which the Medication Administration book is kept. We also put the Medication Administration Policy/Checklist inside the Medication Administration book. |
11/22/2019
| Implemented |
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