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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected and cleaned by a professional furnace cleaning company most recently on 05/28/2020. There was not documentation of prior inspection and cleaning of the furnace; therefore, compliance could not be measured. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Corrective Action Plan-THRIVE Program Director will now begin managing and checking THRIVEs furnace checks . This will be completed by the program director adding a reminder to his monthly calendar to have all furnaces check on a quarterly basis of every home. CEO will then follow up with the Program Director during monthly quality management meetings to ensure this is completed. [Immediately, the CEO or Designee, shall train the Program Director on the requirement that furnaces be inspected and cleaned by a professional furnace cleaning company annually, as required by 6400.106. Documentation of the training shall be kept. The Program Director shall document the aforementioned quarterly audits of furnace inspections. Documentation of monthly Quality Management meetings, to include the review of annual furnace inspections, shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] |
02/11/2021
| Implemented |
| 6400.141(a) | Individual #1, date of admission 07/21/20, had an initial physical examination on 08/03/20. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Corrective Action Plan-THRIVE management team/referral committee will meet prior to accepting a new individual into the program to ensure that all necessary documentation is sent from the previous provider prior to admission. This includes having a physical exam within 12 months prior to admission to THRIVE and annual thereafter. Individual will not be admitted into the program until all documents are sent from previous provider. [Immediately, the CEO, or designee, shall train all staff responsible for admissions on the requirements of individual physical examinations, to include required components and timelines, as required by 6400.141(a-d). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual physical examinations quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] |
02/11/2021
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 07/21/20, had an initial Tuberculin skin testing completed on 08/05/20. | 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. | Corrective Action Plan-THRIVE management team/referral committee will meet prior to accepting a new individual into the program to ensure that all necessary documentation is sent from the previous provider prior to admission. This includes the individual having TB skin testing prior to admission and every 2 years after. Individual will not be admitted into the program until all documents are sent from previous provider. [Immediately, the CEO, or designee, shall train all staff responsible for admissions on the requirements of individual physical examinations, to include required components and timelines, as required by 6400.141(a-d). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual Tuberculin evaluations quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS, on 2/26/2021.] |
02/11/2021
| Implemented |
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