| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | A smoke detector was found on each floor but was not interconnected or audible throughout the home when tested as the residence has three or more stories including the basement and attic. Specifically, there are three floors at Dunlap including 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. | Interconnection was scheduled and completed as of May 21, 2024 |
05/23/2024
| Implemented |
| 6400.112(c) | A fire drill was completed in November of 2023, presumably but we do not know the date, week, or time the drill was completed. | 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. | Retrain staff on the importance of documentation and follow through. |
05/02/2024
| Implemented |
| 6400.112(d) | The fire drill completed on 12/13/2023 exceeded 2.5 minutes and was not reattempted during the month of December to maintain compliance. | 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. | Staff retrained |
05/02/2024
| Implemented |