| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | The Individual Support Plan in use for Individual #1 noted that "all poisons and sharps are kept locked in the home due to [their] long history of poor impulse control." At the time of inspection two large buckets of Kirkland laundry detergent, a gallon of bleach, three gallons of paint and two five-gallon buckets of paint were found in the unlocked basement where the washer and dryer were located. | Poisonous materials shall be kept locked or made inaccessible to individuals. | poisonous materials could cause a serious injury or death to a person when not properly used. This is why this regulation is so important. At the time of the inspection, the basement door was not locked due to laundry detergent being stored in the basement. |
03/25/2024
| Implemented |
| 6400.101 | The door leading to the basement had a keyed lock on the basement side of the door. There are no exterior exits from the basement. Egress from the basement was obstructed by the locked door at the top of the stairs. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| This regulation is to prevent fall caused by obstruction and create a free and non-hazardous escape route especially in the case of emergency. The basement door had the key lock on the basement side. |
03/25/2024
| Implemented |
| 6400.112(c) | Documentation of the fire drill conducted on 3/8/24 did not include notation of the exit used during the drill. | 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. | this regulation is important in keeping date, and time of the drill. Fire emergencies can occur at any time and all documentation should be accurate to ensure our individuals are always aware.
At the time of the inspection, the fire drill conducted on 3/8/24 did not indicate the exit route. Fire drill record has been updated. |
03/25/2024
| Implemented |
| 6400.112(i) | Documentation of the 2/9/24 fire drill does not indicate that a detector was set off during the drill. No smoke detectors were marked as operative. | A fire alarm or smoke detector shall be set off during each fire drill. | this regulation is important in keeping date, and time of the drill. Fire emergencies can occur at any time and all documentation should be accurate to ensure our individuals are always aware.
At the time of the inspection, the fire drill conducted on 2/9/24 did not indicate if the smoke detectors were operative. The drill form was updated. |
03/25/2024
| Implemented |