| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The basement stairs do not have a railing. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Program Manager will be responsible for installing the required railing on the basement stairs to ensure safety compliance.
The Program Manager will verify the completion of the railing installation.
A compliant hand railing will be installed on the basement stairs to meet Chapter 6400 safety regulations.
November 6, 2024: The program manager will oversee the installation of a compliant hand railing on the basement stairs.
November 7, 2024: Installation of the hand railing will begin.
November 7, 2024: Installation was completed.
November 7, 2024: The Program Manager will inspect the railing to ensure compliance with Chapter 6400 regulations.
A thorough inspection of all stairways in the facility has been conducted to identify and address any other non-compliances related to missing or unsafe railings. |
11/07/2002
| Implemented |
| 6400.110(e) | The home is three stories including the basement and does not have an interconnected fire alarm system as there is no smoke detector in the basement. | 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 Program Manager will coordinate with a licensed professional to install the interconnected smoke detector.
The Program Manager will oversee the installation process and verify compliance with Chapter 6400 regulations.
An interconnected smoke detector will be installed in the basement by a licensed professional to ensure the homes fire alarm system complies with Chapter 6400 fire safety requirements.
November 6, 2024: The Program Manager will contract with a licensed professional to perform the installation.
November 7, 2024: The interconnected smoke detector will be installed in the basement and tested for full functionality.
A full audit of all properties under the organizations management will be conducted to verify that all interconnected fire alarm systems are functional and compliant. Any deficiencies identified will be corrected by a licensed fire safety professional. |
11/07/2024
| Implemented |
| 6400.141(c)(10) | Individual 1's physical is missing a statement indicating they are free from communicable diseases from 11/30/2023 date of service. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Program Specialist will be responsible for obtaining the missing statement from Individual 1s physician.
The Program Specialist will verify the documentation is added to Individual 1s file and ensure compliance.
A written statement from Individual 1s physician, confirming that the individual is free from communicable diseases, will be obtained and added to their record.
November 7, 2024: The Program Specialist will contact the physician's office to request the missing documentation.
November 11, 2024: The completed statement will be added to Individual 1s file after verification by the Program Specialist. |
11/11/2024
| Implemented |
| 6400.51(b)(4) | Recognizing and reporting incidents training was not done by staff member 1 prior to working alone with individuals, and within 30 days after hire. | The orientation must encompass the following areas: recognizing and reporting incidents. | The Program Specialist will review all employee training records to identify any staff who have not completed training on recognizing and reporting incidents.
The Training Coordinator will schedule and provide the required training to all non-compliant staff members.
The staff number 1 will complete the Recognizing and Reporting Incidents training immediately.
Training documentation will be updated in the employees personnel file.
November 7, 2024: The Program Specialist will review the staff members training records and schedule training.
November 15, 2024: The staff member 1 completed the required training session.
November 16, 2024: The Program Specialist will update the employee's training file and verify completion.
A review of all current employee training records will be conducted to identify any other staff who may have missed this required training. All non-compliant staff will complete training by December 1, 2024 |
11/15/2024
| Implemented |