Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.81(k)(6) | Individual #1 did not have a mirror in their bedroom at the time of the inspection. | In bedrooms, each individual shall have the following: A mirror. | Due to an emergency staff shortage, Individual #1 was residing at another Bethel Care location for a short period of time prior to inspection. Bethel Care forgot to bring the mirror back to her home. The mirror has been returned. It is the responsibility of the compliance manager to ensure site compliance. The compliance manager will be retrained on this regulation by March 31, 2022. |
03/21/2022
| Implemented |
6400.112(c) | Fire drill documentation that was held 7/26/21 does not indicate if there were any problems encountered during the drill -- this section was left blank. | 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. | The drill on 7/26/21did not indicate whether or not there were any problems encountered during the drill . All Bethel Care direct support staff will be retrained on fire drill forms and this regulation by April 15, 2022. |
04/15/2022
| Implemented |
6400.112(d) | Fire drill held on 6/27/21 states that drill started at 2:00am and ended at 2:03am, which indicates that the drill lasted 3 minutes. This exceeds the 2 ½ minute 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. | ll Bethel Care direct support staff will be retrained on fire drill forms and this regulation by April 15, 2022. It will now be the Program Assistant¿s role to audit the fire drill forms monthly to ensure they are filled out entirely and that the information is correct |
04/15/2022
| Implemented |