| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self assessments for all the currently existent homes that did not open 2019 year were not done within 3-6 months of expiration of license. They were completed on 10/13/19 and the expiration of license was 11/17/19. | 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.
| Jami Residences Operations Manger will ensure Self assessments will be completed 3-6 months prior to the expiration of the Certificate of Compliance. Schedule for June - July 2020. |
06/30/2020
| Implemented |
| 6400.64(a) | The Kitchen sink had food particles sitting in the drain and the Toilet bowl in the main bathroom was unclean with stains and residue. | Clean and sanitary conditions shall be maintained in the home. | Staff no longer has access to the second floor vacant site. The facilities manager will check the site monthly until occupied |
04/01/2020
| Implemented |
| 6400.104 | Notification to the local fire department was not dated, unknown if it was sent upon admission and if it is up to date for the individuals living in the home that need assistance. The form used for all locations does not note when the fire department was notified. | 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.
| The House Manager will notify the Fire Department up admission of each individual person who moves in Jami Residences CLA and ensure that all documents are signed and dated an included in Fire Drill Binder |
04/01/2020
| Implemented |
| 6400.113(a) | Initial fire safety training upon admission on 4/1/19 was not documented in individual 1's record. Annual training was completed on 3/8/2020 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | All consumers will complete a fire safety training and sign a consent form stating it was completed and consumer was trained accompanied with an initial fire drill. Added to annual consent forms |
04/01/2020
| Implemented |
| 6400.181(a) | Initial assessment was not completed within 60 days of admission on 4/1/19 for individual 1. Assessment was not completed until 6/19/19 | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The Program specialist will track all assessment sates on google calendar to ensure that all assessments will be completed in the allotted time frame of -60days |
04/01/2020
| Implemented |
| 6400.181(e)(7) | Heat sources was not discuss in individual 1's assessment dated 6/19/19. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | The program specialist will Identify all information in section with bullet points to be readily available for staff and Support Coordinators to be able to identify |
04/01/2020
| Implemented |
| 6400.181(e)(10) | Lifetime medical history was not found in individual 1's record or attached to the assessment dated 6/29/19. | The assessment must include the following information: A lifetime medical history. | The Program Specialist will attach all Life Time Medical History to all initials assessments |
04/01/2020
| Implemented |
| 6400.181(e)(12) | Recommendations was not discussed adequately in assessment dated on 6/19/19 for individual 1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The program specialist will update plan to ensure that all sections are completed in its entirety and new assessment will be compiled |
04/01/2020
| Implemented |
| 6400.181(f) | Verification was not found in record that team members were given individual 1's current assessment 30 days prior to meeting on 1/14/19. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist will provide a verification cover sheet of date assessments were sent . A copy of that document will be attached to the end of each assessments |
04/01/2020
| Implemented |
| 6400.183(c) | There was no record of who participated in the individual plan meeting for Individual 1's most recent individual plan meeting of 1/14/19; update date was 4/25/19. | The list of persons who participated in the individual plan meeting shall be kept. | The program specialist will complete a packet checklist for content during the ISP meeting to ensure Jami has the documentation to include in service binders for meeting of all individuals that participated. That document will be placed behind the consumer current ISP |
04/01/2020
| Implemented |