| 6500.67 | At the time of the inspection (6/5/2024), there was a large hole in the bedroom hallway ceiling. The drop ceiling was not in place, exposing the ceiling light fixture and wires. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Clarification from the 6400 Regulatory Compliance Guide: Discussion: Cosmetics versus Hazards - This regulation usually does not include minor cosmetic repairs such as faded wallpaper or paint, worn carpeting, or minor damage to baseboards from adaptive equipment. However, if the surfaces in a home are in advanced disrepair, a violation may be cited. Hazardous conditions that result from surface damage ¿ such as peeling paint in a dining area, splintered edges on a doorframe, or frayed carpet that creates a tripping hazard ¿ will be considered a violation.
What is a Hazard? - There is no single list of what constitutes a ¿hazard.¿ While some hazards may be obvious (such as collapsing ceilings and protruding nails), others will be dictated by the needs of the individuals served in the home. For example, a sloped floor in an older home may not pose a risk to mobile individuals, but could constitute a fall risk for an individual with mobility needs. Potentially hazardous conditions will be determined on a case-by-case basis. In some cases, the Department will cite a violation of this regulation if a door leading to a basement, shed, attic, or other part of the home where there are possible hazardous conditions and materials is unlocked. Particular care should be taken when using area rugs that are slippery when stepped on or have curled edges which can be hazardous. The home should assess individuals¿ ambulatory skill to determine if this type of rug is appropriate. A rubber mat or rubber backing under a rug is recommended in all cases, especially in bathrooms where a wet floor could cause serious injury. Providers may develop and implement specific policies relating to ¿good repair¿ and ¿hazards,¿ but that does not preclude the Department from citing a violation if a hazard as described above is observed. Primary Benefit: Safe surfaces help to maintain sanitary conditions in the home, minimize the risk that individuals will suffer an injury while ambulating, and provide dignified living conditions.
FCS Response: The ceiling light was mounted on the floor joist which was behind the drop ceiling panel. The caregiver could not replace the drop ceiling panel without eliminating the light. A hazard is anything that has an increased risk or danger. Any area of the home that is not in good repair can also be considered a hazard. Good repair means the conditions of the home are maintained based on their function. Areas of the home can reflect the age of the home but as things start to become damaged, they need replaced or repaired. Examples: Carpet that is worn and slightly discolored due to age is not a violation. Damaged carpet is any carpet not firmly attached to the floor. Holes in carpet and frayed carpet are considered damaged carpet. If you can see padding or subfloor, the carpet is damaged. Any area of the home that is not finished. Trim needs installed around all doors and windows. Lights need installed so they work as designed and adequately illuminate the intended space.
Immediate Fix: The hallway light will be re-installed so that it provides adequate light with the ceiling panel in place. The caregiver already fixed the light and replaced the ceiling panel.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. All Primary Caregivers will be trained on 6500.67 no later than 7/12/24.
3. The specific violation was corrected on 6/11/24. See picture for validation.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.67 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Training Summary Form for all program staff and the primary caregivers. (Attachment 1)
2. Program check for compliance with 6500.67 (Attachment 2)
3. Picture of corrected ceiling light and drop ceiling panel (Attachment 3) |
07/15/2024
| Implemented |