| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessment was completed late. | 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.
| 6400.15(a) ¿ WHAT and HOW: Self-assessment indeed was completed before December 13, 2017 as were the other homes. Unfortunately, the documentation was not available at the time of the visit. To prevent recurrence going forward, we will use the correct department approved form and scan into a computerized system the completed form to ensure availability.
WHO: Responsibility: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a quarterly review.
WHEN: Date of implementation: May 1, 2018 and ongoing |
05/01/2018
| Implemented |
| 6400.22(d)(1) | June 2017 $19.99 deposit not logged in the financial record. 07/03/2017 funds balance was 34.33. 07/04/2017 balance was 40.32. No deposit to the account was logged in the financial record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 6400.22(d)(1) ¿ WHAT and HOW: The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home.
Between June 1, 2017 and July 4, 2017, there were 3 increases recorded in the individual¿s balance, and no deposits were recorded to correspond to the change in the balance.
A new form for accounting for individual¿s financial and property records was implemented in January 2018 for all houses. This form was reviewed by licensing audit team for January, February and supported. (Comment was that it was perfect). This form is currently in place and has been utilized since January 2018. House Supervisors will train all staff to properly record all deposits and receipts for expenditures so that records are up to date.
WHO: Responsibility: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct monthly reviews of all individuals¿ petty cash records..
WHEN: Date of Implementation: May1, 2018 |
05/01/2018
| Implemented |
| 6400.22(d)(2) | The home did not keep an up-to-date financial and property record for each individual that includes disbursements made to or for the individual Unable to determine balance of account as accurate record is not kept, and receipts are not being logged on the financial record on date of transaction. 07/01/2017 receipt for 5.99 was recorded twice; 08/04/2017 receipt for 3.00 not recorded on financial record; 08/11/2017 10.00 receipt not recorded; 08/12/2017 .89 receipt not recorded; 5.30 receipt not recorded; 08/25/2017 5.39 receipt not recorded; 08/26/2017 6.35 receipt not recorded, but record indicated 10.00 withdrawal; 09/01/2017 records withdrawal of 35.29 for video disc and food and receipt indicated 11.98; 10/07/2017 5.00 receipt not recorded; no date on receipt for snacks 9.00 not recorded; 10/21/2017 5.30 receipt not recorded until 10/25/2017; 10/25/2017 3.00 receipt not recorded; 11/09/2017 indicates balance should be 18.39, balance recorded as 18.41; 11/11/2017 13.97 receipt not recorded; 11/11/2017 13.40 receipt not recorded; 11/18/2017 7.47 receipt not recorded; 11/19/2017 3.00 receipt not recorded; 12/03/2017 3.00 receipt not recorded. 643.00 in cash found in envelope in programming record kept at office. Not recorded on financial log. | (2) Disbursements made to or for the individual.
| 6400.22(d)(2) ¿ WHAT and HOW: Between June 1, 2017 and December 3, 2017, 23 receipts for expenditures were not recorded. To correct this, a new form for accounting for individual¿s financial and property records was implemented in January 2018 for all houses. This form was reviewed by licensing audit team for January, February and supported. (Comment was that it was perfect). This form is currently in place and has been utilized since January 2018. House Supervisors will train all staff in the correct use of our new petty cash form.
WHO: Responsibility: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct monthly reviews of the petty cash records.
WHEN: Date of implementation: May 1, 2018
ADDITIONALLY: Each individual¿s petty cash record for Faithful Homes will also have a review and this will be completed by June 30, 2018. |
05/01/2018
| Implemented |
| 6400.80(a) | Basement outside entrance landing had a large hole partially filled with rocks and covered by two large black plastic pieces. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | 6400.88(a) ¿ WHAT and HOW: All outside walkways shall be free of ice, snow, obstructions and other hazards. There was a hole outside the basement landing which was covered with two boards of hard plastic. This was unacceptable to the auditor. The boards were removed and the hole filled in, picture to be sent to Licensing Director.
WHO: Responsibility: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a quarterly review.
WHEN: Date of implementation March 15, 2018 |
03/15/2018
| Implemented |
| 6400.112(c) | Fire drill log on 09/29/2017 did not include exit route used, the log said 'through.' Fire drill logs did not indicate if the smoke detectors were operative; log only lists number of smoke detectors per floor. | 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. | 6400.112(c) ¿ WHAT and HOW: The fire drill log for 9/29/2017 did not indicate the exit used or whether smoke detectors were operative. To correct this in the future, the department issued fire drill form will be utilized to log all drills and house manager will train all staff on the importance of each item. This form indicates (1) which exit the individuals used, (2) whether smoke detectors where operative. This will be reviewed monthly by the Manager of the house supervisors.
WHO: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a monthly review.
WHEN: Date of implementation May 1, 2018
ADDITIONALLY: All fire drill records for Faithful Homes have been reviewed and were part of the audit. No other issues than what is stated in POC. However, the monthly review process will continue for all homes. |
05/01/2018
| Implemented |
| 6400.112(e) | Individual's date of admission was 06/01/2017. Fire drill during sleeping hours was not held until 12/30/2017. | A fire drill shall be held during sleeping hours at least every 6 months. | 6400.112(e) ¿ WHAT and HOW: It is essential that a sleeping fire drill be conducted at least every 6 months. To assure that a sleeping drill is conducted every 6 months House Supervisors will create a schedule of fire drill for 6 months. This schedule will be reviewed by Manager of House supervisors for approval. It will include the required sleeping drill.
WHO: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a monthly review.
WHEN: Date of implementation May 1, 2018.
ADDITIONALLY: All fire drill records for Faithful Homes have been reviewed and were part of the audit. No other issues than what is stated in POC. However, the monthly review process will continue for all homes. |
05/01/2018
| Implemented |
| 6400.112(f) | Fire drill logs indicated only front entrance was used as an exit route for fire drills conducted from June 2017 to present. | Alternate exit routes shall be used during fire drills. | 6400.112(f) ¿ WHAT and HOW: It is essential that fire drill be conducted using different exits, as any given exit may be blocked in case of an actual fire. To assure different exits are used, House Supervisors will create a schedule of fire drill for 6 months. This schedule will be reviewed by House supervisor manager for approval. It will include the required rotation of exits. Fire drill log will record exit used in documentation
WHO: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a monthly review.
WHEN: Date of implementation May 1, 2018.
ADDITIONALLY: All fire drill records for Faithful Homes have been reviewed and were part of the audit. No other issues than what is stated in POC. However, this process will continue for all homes. |
05/01/2018
| Implemented |
| 6400.112(h) | 08/31/2017 fire drill log did not indicate if individuals met at the designated meeting place. The form was left blank. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | 6400.112(h) ¿ WHAT and HOW: All fire drills must be properly logged to assure that all individuals meet at the designated meeting place. To assure this is corrected going forward, the department issued fire drill form will be utilized, and staff will be trained to properly log each fire drill. This form indicates whether individuals met at the designated meeting place. This will be reviewed monthly by the Manager of the house supervisors.
WHO: House supervisors will be in charge of making the correction and implementing the change, Manager of the House Supervisors will conduct a monthly review.
WHEN: Date of implementation May 1, 2018. |
05/01/2018
| Implemented |
| 6400.186(a) | ISP review dated 12/29/2017 covered the period of September 2017 to November 2017. It was completed late. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | 6400.186(a) ¿WHAT and HOW: The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. ISP review completed 12/29/2017 was completed late. To prevent recurrence and to assure all ISP¿s are reviewed on time, Program specialist will create a spreadsheet checklist. This checklist will be monitored by the manager of the program specialist weekly to ensure that all dates are met.
WHO: Responsibility: Program specialist will conduct the record review and will be correcting any findings, Manager of Program Specialist will check the work on a quarterly basis.
WHEN: Date of implementation May 1, 2018.
ADDITIONALLY: Each individual¿s record for Faithful Homes will also have a review and this will be completed by June 30, 2018. |
05/01/2018
| Implemented |