| 6400.106 | Furnace in the home was inspected and cleaned by a professional furnace cleaning company on 12/02/22, and then again on 02/20/24. This exceeds the annual requirement. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Facility will ensure all furnaces shall be inspected and cleaned at least annually by an external professional furnace cleaning company regardless of the house being empty with no individuals at the time of furnace inspection is due. An in-service is given to the Maintenance Manager to make sure all furnaces are inspected yearly by coordinating the inspections with external professional company to be completed 2 months before the end of the year to ensure compliance. This in-service was completed on 03/24/2024. In addition, all inspected furnace documents are to be submitted to the resident services director for review two months before the end of the year to ensure compliance. The Sr. residential director will monitor that this process is followed, and all documents are in good order and are accounted for one month before the end of the year to ensure compliance and prevent similar future incidents. |
03/24/2024
| Implemented |
| 6400.112(f) | Fire drills conducted from 04/01/23 through and including 09/22/23 utilized the front/door main entrance as the exit for all drills. The home has more than one exit. | Alternate exit routes shall be used during fire drills. | The facility has already in-serviced the house Manager and the program Specialist on making sure that they are using alternate exit routes when conducting fire drills. In addition to the in-service, the program specialist manager will review the fire drills each month to ensure that alternate exit routes are used when possible. The resident services director will monitor this process by checking fire drills quarterly to ensure compliance and prevent future similar incidents.
It should be noted that this deficiency should be cited for the following reasons:
1. The individual who lived in this house from April 2023 to October 2023 could not do steps; he uses walker/ wheelchair to ambulate with staff assistance.
2. It is also documented in his ISP.
3. HRST also states the same thing, using a walker with staff assistance and should not use steps.
4. 6400.102 states that ¿if four individuals sleep above the ground floor, there shall be a minimum of two interior or exterior exits from each floor¿. In Clover house where we received the deficiency, there is only one main exit that the individual who lived there could use safely since he could not do step. The other exit has deep narrowed steps, and that is the reason why we did not use the second exit as an alternate. I mentioned 6400.102 because it did not mention that you have to have two exits if you have 3 or less individuals living in the house. We are aware that we need to alternate exits when conducting fire drills. I was pointing out that if you have only when safe exit, how can you alternate? |
03/27/2024
| Implemented |