| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | At the backdoor exit outside had a lot of debris and a trashcan, which need to be cleaned and a trash bag need to be inside the trashcan to prevent rodents. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The backyard was cleaned up immediately. Staff will put trash out on Thursday's and keep the backyard cleaned. Outside trash cans were purchased to put the trash in leading up to trash day. The backyard will be cleaned weekly by direct support. |
02/01/2024
| Implemented |
| 6400.65 | The Mechanical ventilation in the hallway bathroom was not working., and no work order was provided. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Our maintenance team will do a walk through immediately, and fix all items needed to be repaired. Direct support will fill out a maintenance log as damages/ repairs are done. |
02/05/2024
| Implemented |
| 6400.67(a) | The walls had patches throughout the home, due to individual 2 acting out. No work order was provided. | Floors, walls, ceilings and other surfaces shall be in good repair. | Our maintenance team will do a walk through immediately, and fix all items needed to be repaired. Direct support will fill out a maintenance log as damages/ repairs are done. The walls were painted. |
02/01/2024
| Implemented |
| 6400.73(a) | There was no handrail leading to the basement. A handrail needs to be installed to ensure individual's safety is being met. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Handrail was completed the next day pictured will be uploaded. |
02/01/2024
| Implemented |
| 6400.112(a) | There was no fire drill found for September 2023, it was requested but not provided. | An unannounced fire drill shall be held at least once a month. | All direct support staff will be retrained on conducting fire drills. Ex. when they should be conducted etc. |
02/01/2024
| Implemented |
| 6400.112(d) | On October 15,2023, fire drill was over the 2 1/2-minute requirement, and home did not conduct another fire drill or document an issue per 6400 regulations. | 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 |