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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | On 4/12/2023 the exit to the back yard of the home, did not have operable lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 4/13/2023, the Director had a motion-sensor light placed near the back door. (Pic #9) The House Supervisor was retrained on the Lighting, Surfaces, Unobstructed Egress Policy on 4/13/2023. (Pic #15) [Documentation via photograph of a motion-sensor light placed outside of the rear entrance/exit of the home was received on 5/10/23 and reviewed 5/22/23. Documentation of training, dated 4/13/23, related to "Lighting, Surfaces, and Unobstructed Egress" was received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.101 | On 4/12/2023 the basement storage room containing poisons, had a padlock on the outside of the door presenting an entrapment risk. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Director spoke to the House Supervisor on 5/4/2023 to remove the padlock on the small basement storage room. The padlock and the poisons were removed. (Pic #6) [Documentation via photograph of the removed pad lock and poisonous materials was received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff, completed between 5/6/23 and 5/9/23, related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.112(f) | The fire drills completed 10/20/2022 and 1/11/2023 states the individual used the garage door as the exit route. The garage does not contain a swing door as an egress. | Alternate exit routes shall be used during fire drills. | The Fire Drill form and the Fire Drill Policy was updated on 5/4/2023 (Pic #5) to include the statement that a garage door cannot be used as a fire drill exit. A fire drill using the updated form was run on 5/4/2023 with all individuals present. (Pic #7) Staff discussed with the individuals that they would not be using the garage door as a fire drill exit. [Documentation of the Fire Drill Policy and TLHHC Monthly Fire Drill Report were received on 5/10/23 and reviewed 5/22/23. Documentation of training for all residential staff, completed between 5/6/23 and 5/9/23, related to "POC Training: Running Water, Surfaces and Lighting, Unobstructed Egress, Fire Evacuation" was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
| 6400.32(r)(4) | Individual #1 had a privacy lock on their bedroom door which does not allow easy and immediate access by the individual and staff persons in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | The Privacy Lock Policy was updated on 5/4/2023 to include the updated language that bedroom doors should be equipped with a key lock to the outside and a doorknob tab on the inside. (Pic #10) The bedroom door¿s doorknob was replaced with a key lock on the outside and a doorknob tab on the inside on 5/6/2023. (Pic #11) The individual was trained on the updated policy on 5/6/2023. (Pic #12) [Privacy Lock Policy that includes that "[d]oors shall be equipped with a key lock on the outside and a thumb-turn lock on the inside" was received on 5/10/23 and reviewed 5/22/23. Documentation via photograph that a door lock, in accordance with the agency's policy, has been installed was received on 5/10/23 and reviewed 5/22/23. Documentation that Individual #1 was retrained on the Privacy Lock Policy, dated 5/6/23, was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
06/04/2023
| Implemented |
| 6400.186 | Individual #1's assessment completed 12/06/2022 states the individual is able to evacuate independently. Individual #1's individual support plan (ISP), last updated 1/04/2023, states the individual needs verbal prompts to evacuate. | The home shall implement the individual plan, including revisions. | The Program Specialist reviewed the individual¿s ISP and spoke with the individual and staff. Staff confirmed that the individual may need a verbal prompt to evacuate. The Program Specialist revised the 6400 Assessment on 5/4/2023 to read that the individual may need a verbal prompt to evacuate a fire. (Pic #13) The Program Specialist emailed the revised assessment to the ISP team on 5/8/2023. (Pic #14) [Documentation of Individual #1's updated assessment, dated 5/4/23, was received on 5/10/23 and reviewed 5/22/23. Documentation of communication of Individual #1's updated assessment to plan team members, dated 5/8/23, was received on 5/10/23 and reviewed 5/22/23. DPOC by HDKP, HSLS, on 5/22/23]. |
05/08/2023
| Implemented |
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