Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.61(a) | During the fire drill conducted onsite on 8/17/17, staff had to provide Individual #1 with physical assistance to evacuate through the kitchen door egress due to the large step down at that egress point. They exited through the kitchen door that leads to the garage. That kitchen door egress route has a single, large, drop down step to the garage floor and there isn¿t a handrail to assist Individual #1. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Construction of step leading from kitchen to garage was done on 10/1/17 due to individual #1 needing physical assistance when evacuating. See Attachments #57a & 57c |
10/01/2017
| Implemented |
6400.62(a) | Individual #1 is assessed to be unsafe around poisonous substances. Hydrogen Peroxide that contained a label to contact poison control center was unlocked and accessible in the first aid kit located in the downstairs laundry room. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 8/18/17 the first aid kit was locked under kitchen sink so individual #1 has no access to poisonous substances. |
08/18/2017
| Implemented |
6400.72(b) | The plastic guard on the front screen door was broken and cracked leaving it attached to the door by only three corners instead of four. | Screens, windows and doors shall be in good repair. | Program Specialist removed the broken plastic guard from the inside of screen door on 8/18/17. See attachment #58. |
08/18/2017
| Implemented |
6400.80(b) | Tree branches were located in and over flowing out of approximately a 6 foot section of gutter located over the back deck. Siding on the back of the house near the kitchen widow had approximately a 1-2 foot crack, exposing material underneath the siding. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Program Specialist removed the branches from the gutter on 8/18/17. See attachment #56
Siding on back of house was replaced on 10/1/17. See Attachments #57a & 57b. |
10/01/2017
| Implemented |
6400.103 | REPEAT from 12/14/16 annual inspection: The written evacuation procedure indicated that 2 males living in the home will share a hotel room for their emergency shelter. No males reside in the home. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Program Specialist immediately updated the emergency evacuation plan on 8/17/17. See attachment #55 |
08/17/2017
| Implemented |
6400.104 | On 12/9/15 the home notified the fire department that Individuals #2 and #3 were independent with evacuation in the event of a fire. However Individuals #2 and #3 require visual prompting with strobes lights and the physical assistance of a bed shaker in order to evacuate the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Specialist updated letter to fire department on 8/30/17 addressing Individual # 2 and #3 who require visual prompting with strobe lights and physical assistance of bed shaker in order to evacuate the home. See Attachments # 54a, 54b & 54c. |
08/30/2017
| Implemented |
6400.110(f) | Individual #2 is deaf and cannot hear the fire alarm. He/She requires the assistance of strobe lights and a bed shaker to notify him/her to evacuate the home in the event of a fire. Individual #2 utilizes up to 3 hours of unsupervised time at his/her home however he/she does not have a personal body device to notify him/her in the event of a fire should he/she be sleeping on couches or chairs throughout his/her home when staff are not at home. Individual #3 utilizes unsupervised time at the home however he/she also does not have a personal body device to notify him/her in the event of a fire should he/she be sleeping on couches throughout his/her home when staff are not home. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Email sent 10/06/17 at 11:12 a.m. to Mj Shahen at ODP concerning body devices for Individual #2 and Individual #3. See Attachment #53
Intertech was called to put shakers on Living room chair and couch. Intertech ordered shaers and will put on chair and couch when received. Expected date 11/24/17. |
11/24/2017
| Implemented |
6400.112(a) | The fire drills are not unannounced. At the beginning of the year, the program specialist created a list that indicated the month, day, year, the person responsible for completing the drill, and the date and time frame for the overnight drills. This list is kept at the home in the fire drill book for all staff to see. | An unannounced fire drill shall be held at least once a month. | Fire Drill schedule was changed in fire book immediately on 8/17/17 as per regulation. See attachment #52 |
08/17/2017
| Implemented |
6400.185(b) | Individual #1 has two new outcomes; to have staff instruct Individual #1 on a daily basis on how to open the gates on the steps and to have staff instruct Individual #2 on a daily basis on the importance of not touching or eating hot foods, eating too fast and safety risks around hot items (stove, oven, crockpot, etc). These outcomes were initiated on 8/9/17. Licensing was at the home on 8/17/17 and for the month of August after the implementation date, there was no documentation that these outcomes were worked on daily as written on 8/11, 8/12, 8/13, 8/16, or 8/17. | The ISP shall be implemented as written. | Memo sent to all staff and sub aides that work at Vinco home, concerning outcomes that were not documented daily as written per ISP and 6400 state regulations. See attachment ##9 |
10/18/2017
| Implemented |