| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | The home has three stories including a basement, the smoke detectors on each floor are not interconnected and audible throughout the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The home listed in this citation did have an interconnected audible smoke detectors on all floors of the facility; however, it was not program at the time of the inspection. Quality Angels programmed all of the devices immediately after the inspection. A follow up inspection was schedule on 8/29/22 and the inspector witness the demonstration of the alarms in action. |
08/24/2022
| Implemented |
| 6400.141(a) | Individual 1 did not have a full physical within a year prior to their admission to the agency on 5/18/22. A physical from 3/29/22 was provided that did not include documentation of vision, OB/GYN, PAP, and mammogram tests or exams. Considerations of physical limitations, medical information pertinent to diagnosis in case of emergency, and special diet information were also not documented. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Due to an emergency placement, the individual 1 came into our program with missing medical information. The individual was new to residential services and was not attending her medical appointments prior to her enrollment into our residential program. She came into our program with a recent physical. We were unable to schedule a new physical due to the annual nature of physicals. Quality Angels has since scheduled all of the individual medical appointments and has completed most of the appointments. As for the mammogram, the individual was under the age of 40 when she transitioned into our residential program. The mammogram is only schedule for individual above 40-year-old or if there is a concern. Quality Angels has scheduled a mammogram for the individual which is scheduled for mid-October. |
11/01/2022
| Implemented |
| 6400.141(c)(6) | Individual 1 did not have a TB test prior to their admission. | 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. | Quality Angels accepted the individual into our program due to the emergency nature of the case without a TB test. Quality Angels immediately scheduled a TB test for the individual. The TB test was completed on 9/14/22 and the result was negative. |
10/01/2022
| Implemented |
| 6400.151(a) | Staff Member 3 did not have a physical within a year prior to their hire date of 6/10/22. Documentation was requested but not received. | 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. | Staff Member 3 (program specialist) immediately scheduled a physical exam to be in compliance with the ODP regulations. The earliest appointment date available was 10/28/22. Once the appointment is completed, the file for the staff member will be immediately updated. |
11/01/2022
| Implemented |
| 6400.181(e)(12) | Individual 1's 6/19/22 assessment did not include recommendations for training, programming, or services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The individual 1 is very new to residential therefore our management team was giving more time for observation before recommendations can be made. Moving forward, Quality Angels will ensure that a preliminary recommendation is made during the first assess regardless of the amount of time the individual has spent in our program. |
11/01/2022
| Implemented |
| 6400.46(b) | Staff Member 1's 5/27/22 and Staff Member 2's 5/21/22 fire safety trainings were not provided by a fire safety expert. Credentials for the trainer, Staff Member 3, were requested but not provided. Staff Member 3 also has not received fire safety training from a fire safety expert. The agency did not have credentials on file for the trainer who provided their October 2021 fire safety training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Quality Angels hired a fire safety expert to conduct our fire safety training; however, although the fire safety trainer had their credentials, we did not request their trainer¿s credential. Moving forward Quality Angels will verify source of the credentials of any instructor hired to perform trainings. Once the credentials are verified, Quality Angels will maintain a record of the verified credentials. Quality Angels has also contracted a new verified company to conduct the fire safety trainings. The first training was completed on Wednesday 9/21/22 and the Second training is scheduled for Friday 9/30/22. |
11/01/2022
| Implemented |
| 6400.52(c)(3) | The CEO's 2021 annual training did not cover individual rights. Documentation of a training covering this topic was requested but not provided. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The CEO was in attendance at the individual rights training conducted at our office location, however, records of the training was not documented. Moving forward the CEO will complete and maintain records of this training annually. The CEO also retook this training on myodp.org site on 9/27/22 to ensure compliance. |
10/01/2022
| Implemented |