| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(b) | The deck, located outside the kitchen, has a splintered handrail. | Each porch that has over an 18-inch drop shall have a well-secured railing. | Splintered handrail was repaired 10/14/2015. Quarterly the Residential Manager will complete a checklist and conduct a physical site inspection. The results of the inspection will be submitted to Program Specialist to verify that this regulation is in compliance. The checklist will include doing a walk through of the home to ensure compliance. The checklist will be sent via email as attachment #8. |
10/14/2015
| Implemented |
| 6400.101 | The basement door has a key lock preventing exit to the outside. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Lock was removed from basement door. Attachment #5 sent via email indicates that the basement exit will be used in rotation of exits during monthly fire drill. During all monthly fire drills doors will be inspection to ensure they do not have a key lock that prevents exit. When opening new locations, Program Specialist and Residential Director will indicate on self inspection form if any locks need to be removed to ensure exits are unobstructed. |
10/30/2015
| Implemented |
| 6400.112(a) | The fire drill book contained projected fire drills scheduled until 5/11/2016. The fire drill book is available to all staff working in the home. | An unannounced fire drill shall be held at least once a month. | The Program Specialist completed new fire drill schedules that are only accessible to the Residential Manager including using alternate exit routes to be used during fire drills. Ongoing when a new location is in operation the Program Specialist will indicate the need to rotate exits on the schedule an train the Residential Manager on the schedule and to not share with individuals or direct care staff. All current Residential Managers were retrained on 9/24/2015. Sign in sheet for training is being sent via email as attachment # 6. Fire Drill schedules will be sent via email as attachments #3, 4, and 5. |
09/24/2015
| Implemented |
| 6400.112(f) | The fire drills conducted for the year utilized the front door as the exit route. | Alternate exit routes shall be used during fire drills. | The Program Specialist completed new fire drill schedules that are only accessible to the Residential Manager including using alternate exit routes to be used during fire drills. Ongoing when a new location is in operation the Program Specialist will indicate the need to rotate exits on the schedule an train the Residential Manager on the schedule and to not share with individuals or direct care staff. All current Residential Managers were retrained on 9/24/2015. Sign in sheet for training is being sent via email as attachment # 6. Fire Drill schedules will be sent via email as attachments #3, 4, and 5. The Program Director will reveiw the fire drill records upon completion on a monthly basis to ensure that alternative exits are used and if not a second drill will be conducted to ensure that all residents are familiar with alternative exits in the event of an emergency evacuation, starting within 30 days of receipt of this plan of correction. [SW 11.20
.15] |
09/24/2015
| Implemented |