| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | On 11/15/2023, staff interviews and financial ledgers revealed that Individual #1 and Individual #2 are being required to provide the cleaning and laundry supplies for the home from their personal funds. | Individual funds and property shall be used for the individual's benefit. | On 12/14/2023 individual 1 and 2 was reimbursed for supplies and laundry. The agency representative responsible for making this correction was (site supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collected and not just room. The agency representative that was responsible for the change was supervisor (supervisor). The agency representative will monitor the individual¿s funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/14/2023
| Implemented |
| 6400.62(a) | At 11:04 AM on 11/15/23, the lock on the cabinet doors underneath the kitchen sink of the home containing poisonous substances was observed not fully engaged, allowing space for the individuals to access them. Individual #1 is not assessed to be safe with poisons. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 11/17/2023 a metal storage cabinet was purchased and delivered on 11/24/2023. The poisonous material was placed and locked in the storage cabinet by agency representative. The site supervisor will monitor if the poisonous material is being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. |
11/24/2023
| Implemented |
| 6400.101 | On 11/15/23, there was a sliding chain latch-lock found on the front exit door of the home, posing a possible entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| On 12/6/2023 the maintenance man removed all chain locks from the door. Leasing office was informed that those type of locks cannot be used in the future. On 12/07/2023 the Program Specialist check all locations to ensure locks were removed. The site supervisor will monitor locks on lead checklist monthly to ensure compliance is being met, Program Specialist will monitor lead checklist monthly and site location quarterly to ensure compliance is being met for 1 year. The CEO trained the Program Specialist on appropriate lock systems and when and how they should be used. |
12/07/2023
| Implemented |
| 6400.112(c) | The written fire drill record provided from 12/7/22 to 10/10/23 is a three-page chart documenting all fire drills conducted. Near the bottom of each page is a field with two blank lines to document any problems encountered during the fire drill. However, any information provided in this field is not referenced specifically to any one fire drill. Therefore, compliance could not be measured to determine if all fire drills provided in the written fire drill record address problems encountered. | 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. | On 11/21/2023 the agency representative (Administrator assistant) updated the Fire evacuation record/fire system check sheet to reflect problems during fire drill being kept and tracked every time a fire drill is being performed. The new procedures will be implemented on upcoming fire drills and every fire drill thereafter. The site supervisors will check each fire drill log to ensure compliance is being met, tracking will be completed on lead checklist to prevent the violation from occurring again. This tracking system will apply to every fire drill performed. 11/21/2023 CEO trained Program Specialist and Supervisors on updated Fire Evacuation Record. |
11/21/2023
| Implemented |
| 6400.216(a) | At 11:20 AM on 11/15/23, binders containing personal records and documents related to Individual #1 and Individual #2, including but not limited to their assessment, individual plan, physical and dental examinations, were discovered on the floor of the dining room. | An individual's records shall be kept locked when unattended.
| On 11/17/2023 the agency purchased a file cabinet with a locking system to store binders appropriately. On 11/20/2023 the binders were placed in the file cabinet by site supervisor to be stored appropriately. The site supervisor will monitor if the binders are being stored appropriately on the lead checklist monthly. The Program Specialist will monitor the lead checklist monthly and site location Quarterly to ensure compliance is being met. On 11/21/2023 the CEO trained the program specialist and site supervisor on the appropriate way to store main files and the tracking system that will be used to ensure compliance is being met. |
11/20/2023
| Implemented |
| 6400.24 | On 11/15/2023, staff interviews and financial ledgers revealed that Individual #1 and Individual #2 are being required to provide the cleaning and laundry supplies for the home from their personal funds. Chapter 6100.684(d)VII requires that laundering of towels, bedding, and individual clothing be provided as part of room and board. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 12/14/2023 individual 1 and 2 was reimbursed for supplies and laundry. The agency representative responsible for making this correction was (site supervisor). On 12/01/2023 the agency updated and signed a new room board contract along with the individual to reflect room and board being collected and not just room. The agency representative that was responsible for the change was supervisor (supervisor). The agency representative Joanne Walker will monitor the individual¿s funds quarterly to ensure prevention of misuse of funds and all guidelines are being met. On 12/1/2023 the CEO trained the agency representative on the policy, implementation and guidelines of the updated room and board contract, and management of the individuals funds. |
12/14/2023
| Implemented |