Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00159846 Renewal 07/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 6/4/19 at 4:15PM had an evacuation time of 2 minutes and 34 seconds. The home does not have an extended evacuation time. 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. On August 7 & 8, 2019, the Director of Quality Assurance and Training retrained all the program managers on regulation 6400.112(d) and the requirement to contact administration for corrective action if a drill¿s evacuation time exceeds the 2 minutes and 30 seconds. The outline and sign in sheet are attached for review. To ensure no further infractions occur, the ¿Record of Fire Drill¿ form will be reviewed monthly by the designated Operations Director for accuracy starting August 2019. The Quality Assurance department will complete random checks of the Fire Drill records throughout the year, ensuring each homes record is reviewed at least bi-annually for accuracy, starting August 2019. Documentation will be kept within the Quality Assurance department. 08/07/2019 Implemented
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