| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.101 | During the 7/22/21 inspection, Individual #1's bedroom door would not open entirely due to items in their room preventing the door from opening. There were multiple pairs of shoes witnessed immediately inside the individual's bedroom, creating numerous tripping hazards in the doorway/exit from their room.
The stairs leading to the attic were completely covered in household items, blocking access to the attic. The steps themselves could not been seen due to all the items sitting on the steps. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | Providers Plan of Correction:
1. Immediate fix: 100 Darr Ave will remove clutter from the client bedroom and closet to the attic no later than 8/27/21.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The Life Sharing Specialist will complete a monthly review to evaluate the clutter in the home. The first review will be completed by 8/27/21.
6. A program check will be conducted in all homes not inspected no later than 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A picture of the bedroom and closet (Attachment #15 and #16) showing compliance with the clutter will be sent to ODP no later 9/30/21.
6. Monthly tracking form to monitor clutter in the home (Attachment #18).
7. Program check log sheet (Attachment #17) will be completed and sent to verify compliance in all homes not inspected no later than 9/30/21. |
09/30/2021
| Implemented |
| 6500.107(a) | The home is equipped with an attic and per the family living provider, a smoke detector is 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. | Providers Plan of Correction:
1. Immediate fix: 100 Darr will install a smoke detector in the attic crawl space immediately.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. The revised smoke detector check form will be completed no later than 8/27/21.
6. A picture of the new smoke detector in the attic will be completed no later than 9/30/21.
7. A program check will be conducted in all homes not inspected no later than 9/30/21.
8. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. The revised and completed smoke detector check form will be sent to ODP no later than 9/30/21 (Attachment #22).
6. A picture of the smoke detector in the attic will be sent to ODP no later 9/30/21 (Attachment #23).
7. Program check log sheet (Attachment #24) will be completed and sent to verify compliance in all homes not inspected no later than 9/30/21.
8. Copy of obsolete smoke detector check form to show revision changes (Attachment #25). |
09/30/2021
| Implemented |
| 6500.108(a) | The home is equipped with an attic and per the family living provider, a fire extinguisher is not located in the attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Providers Plan of Correction:
1. Immediate fix: 100 Darr Ave. will install a fire extinguisher in the attic immediately.
2. Program Director, will train all Team Supervisors on the regulation no later than 8/27/21.
3. The Team Supervisors will train all Life Sharing Specialists on the regulation no later than 8/27/21.
4. The Life Sharing Specialists will train all primary caregivers on the regulation no later than 8/27/21.
5. A picture of the new fire extinguisher in the attic will be completed no later than 8/27/21.
6. A program check will be conducted in all homes not inspected no later than 8/27/21.
7. If any additional violations are found, they will be corrected no later than 9/30/21 or an extension will be requested.
Attachments:
1. Attachment Log Sheet to organize all the attachments with a reference number (Attachment #1). A copy will be sent to ODP no later 9/30/21.
2. Training Summary Form for all Team Supervisors (Attachment #2). A copy will be sent to ODP no later 9/30/21.
3. Training Summary Form for all Life Sharing Specialist (Attachment #3). A copy will be sent to ODP no later 9/30/21.
4. Training Summary Form for all Primary Caregivers (Attachment #7). A copy will be sent to ODP no later 9/30/21.
5. A picture of the fire extinguisher in the attic will be sent to ODP no later 9/30/21 (Attachment #32).
6. Program check log sheet (Attachment #31) will be completed and sent to verify compliance in all homes not inspected no later than 9/30/21. |
09/30/2021
| Implemented |