| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | There were no emergency telephone numbers posted on or near the telephone located in the home's living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Emergency Phone list was posted in the spare bedroom as per regulation. |
10/05/2025
| Implemented |
| 6400.112(e) | Per the fire drill record for this location, a fire drill took place during sleeping hours on 04/14/2025. There was no other record of a fire drill occurring during sleeping hours within the October 2024 to September 2025 review period. A fire drill was not held during sleeping hours at least once every 6 months at this location as required. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Manager's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (e). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. Quality Assurance Manager will provide monthly updates to Program Managers on when required sleep drills are to take place in addition to their individual tracking of such. |
10/05/2025
| Implemented |
| 6400.112(h) | The fire drills for this location did not note whether all of the individuals residing in the home evacuated to the designated meeting area outside of the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Program Manager's and DSP's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (h). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. All employees and consumers will be trained on meeting places for their respective sites. |
10/05/2025
| Implemented |