| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.73 | REPEAT from 5/14/19 annual inspection: The interior stairway leading from the third floor to the attic, included 12 steps, and was not equipped with a handrail. | An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail. | Interior stairwell leading from the 3rd floor to the attic level had an existing handrail that was there during the annual inspection date of 7/30/202. Hand rail is painted the same color as the walls and may have been hard to see during the remote inspection walk through of the home |
07/31/2020
| Not Implemented |
| 6500.74 | REPEAT from 5/14/19 annual inspection: The 12 steps leading from the third floor to the attic and the 20, interior steps located towards the back of the home, leading from the first floor to the second floor were not equipped with a non-skid surface. The steps were a lacquer-finished wood. | Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface. | The attic is not accessed by the individual due to the steps leading to the attic being extremely steep and having very narrow treads (cannot place a whole foot on them) and there is no floor in the attic space However the attic steps were cleaned and skid strips have been added to the painted steps leading to the attic.
Non-skid strips were installed on painted back steps leading from the first floor to the second floor.
The Lifesharing Specialists will visually inspect all stairs for non-skid strips during each monthly visit and will immediately address any issues noted on the checklist with the LSP prior to leaving. The Lifesharing specialist will ensure any issues noted on the checklist are corrected in a timely manner. Proof of the correction will be submitted to Residential Director upon completion. |
08/31/2020
| Implemented |
| 6500.101 | Family member #1 could not open the attic door easily during the 7/30/2020 remote inspection. She was holding an cellular telephone to complete a remote inspection with the licensing representative and had to place her telephone on the ground so she could pry open the door with both hands.
· The door leading from the foyer/entryway of the home to the porch egress could not be opened during the remote inspection. A large, plastic, storage tub of shoes was sitting in front of the door and the door was partially painted shut. Family member #1 could only manage to open the door a small crack.
· The doorway leading from the foyer to the living room was completely blocked by the television entertainment center in the living room.
· The back stairway leading from the first floor to the second floor was obstructed with clutter at the bottom of the stairway. A mound of clothes, jackets, bags, and other household items were piled up on the bottom landing of the stairwell. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | Attic is not considered an exit as there is no floor- floor is just insulation and cannot be walked on as this would lead to someone falling through the attic to the floor below.
All obstructions have been cleared from in front of the foyer/entryway.
Living room doorway was screwed closed and is no longer considered an egress, all doors exterior doors have been cleared of obstructions.
Coats on coat rack in back stairway do not obstruct the egress however the landing has been cleared of all clutter.
The Lifesharing Specialists will visually inspect all doorways, stairways, hallways and exit during each monthly visit and will immediately address any issues noted on the checklist with the LSP prior to leaving. The Lifesharing specialist will ensure any issues are noted on the checklist and are corrected in a timely manner. Proof of the correction will be submitted to Residential Director upon completion. |
08/31/2020
| Implemented |
| 6500.107(a) | The attic of the home was not equipped with a smoke detector. During the 7/30/2020 remote inspection of the home, Family member #1 confirmed a smoke detector was not located in the attic. Staff person #2 confirmed during the 7/31/2020 exit conference that Family member #1 told her a smoke detector was not located in the attic. | A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic. | Smoke detector was installed in the attic.
Lifesharing provider was retrained on regulation 6500.107(a)
The Lifesharing Specialists will view all floors and verify working smoke detectors during each monthly visit and will immediately address any issues noted on the checklist with the LSP prior to leaving. The Lifesharing specialist will ensure any issues noted on the checklist are corrected in a timely manner. Proof of the correction will be submitted to Residential Director upon completion. |
08/31/2020
| Implemented |
| 6500.17(a) | The agency did not complete an entire self-assessment of the home. During the 7/30/2020 remote inspection of the home, Family member #1 reported that the physical site and fire safety violations described in 6500.73, 6500.74, 6500.101, 6500.107(a), 6500.108(a), and 6500.108(b) of this report, have been like that for years. The 5/19/2020 self-assessment of the home, did not include the name of the person completing the self-assessment and did not include violations found at the home.
· Staff person #2, management staff responsible for oversight of the home, reported to licensing personnel on 7/30/2020 that she was unaware the home had an attic, that the provider had access to an attic, or that there wasn't a smoke detector and fire extinguisher located in the attic. When completing a self-assessment of the home, the agency representative is to complete a physical inspection of the home that would include checking for an attic and ensuring a smoke detector and fire extinguisher are located in the attic. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | During the time of the self-assessment and monthly home visit no issues were noted for regulation 6500.108(b) as the fire extinguisher is and was located in the breakfast nook of the kitchen and this is considered one room.
The Lifesharing Specialists was retrained on the above regulation 6500.17(a) self-assessment by the Residential Director. |
09/01/2020
| Implemented |