Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.82(f) | The bathroom had antibacterial hand soap. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The above mentioned bathroom had soap in and unlabeled dispenser. The hand soap refill bottle was located under the bathroom sink. It was shown at time of inspection. All soap bottles/dispensers will have labels on them showing the name and contents. |
01/31/2024
| Implemented |
6400.112(c) | The exit route was not indicated on the form. | 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. | All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. |
02/05/2024
| Implemented |
6400.112(c) | On 9/16/23, the form did not indicate if alarms were operable. | 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. | All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. |
02/05/2024
| Implemented |
6400.112(d) | On 12/18/23 and 11/2023, fire drill was over 3 1/2 minutes, no other fire drill was conducted, or problem identified to show why the fire drill went over 2 1/2 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All direct support staff will be retrained on fire drill evacuation times. No consumer fire drill should exceed 2.5 minutes or within the period of time specified in writing within the past year by a fire safety expert. Direct support will report any fire-drills that lasts over 2.5 minutes directly to management immediately. |
02/05/2024
| Implemented |
6400.112(i) | On 7/3/23, the fire drill form did not indicate what alarm was used. | A fire alarm or smoke detector shall be set off during each fire drill. | All direct support staff will be retrained on filling out the fire drill log in its entirety. Supervisors will check every thirty days to ensure every line/box area etc is filled out. |
02/05/2024
| Implemented |