Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Dawn dish soap, glass cleaner, Tilex and Scrubbing Bubbles were unlocked under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All staff, Program Specialists, and Supervisors were retrained on ensuring all poisonous materials are locked at all times. A new lock was purchased for the cabinet to ensure it is properly locked and does not come open. This will be monitored by the supervisor monthly on the structural survey, included on POC and second checked monthly by Program Specialist. |
10/01/2016
| Implemented |
6400.62(c) | There was a clear bottle with approximately 18 fl oz. of purple liquid unlocked under the kitchen sink. Staff indicated it was Fabuloso cleaning solution. | Poisonous materials shall be stored in their original, labeled containers. | All staff, Program Specialists, and Supervisors were retrained on ensuring all poisonous materials are in their original labeled container. A new lock was purchased for the cabinet to ensure it is properly stored at all times. This will be monitored by the supervisor monthly on the structural survey, included on POC and second checked monthly by Program Specialist. |
10/01/2016
| Implemented |
6400.112(c) | The 02/17/16 fire drill log did not indicate if all alarms were operative. All smoke detectors are not being tested monthly according to staff interviews. | 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. | All Supervisors were retrained on checking the alarm systems and to ensure they are working properly. This will be done monthly during fire drills and completing the monthly structural survey. Program Specialists will then check to ensure these things are completed correctly monthly. A Fire drill was completed in late September to verify this was completed and a monthly structural survey in early October will be included in POC. |
10/03/2016
| Implemented |
6400.112(h) | The 08/03/15 fire drill log indicated not all individuals in the home met at the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | All Supervisors were retrained on ensuring during a fire drill that all individuals evacuate to the designated meeting place. This will be done monthly during fire drills. Program Specialists will then check to ensure these things are completed correctly monthly. A fire drill was completed in September to verify this was done properly. |
10/03/2016
| Implemented |