| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment was completed late. The expiration date of the Agency's certificate of compliance is 8/01/2019 and the self-assessment was completed on 8/14/2019. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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. | IHRS will develop a protocol that requires all self assessments to be completed by May 1st of the current calendar year. This will ensure that all homes are assessed prior to the expiration date of our certificate of compliance. Our compliance manager, will ensure that these assessments are completed. |
10/31/2019
| Implemented |
| 6400.67(a) | A knob was missing on the closet door in Individual #1's bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Request has been submitted to the maintenance contractor for repair. Monthly house check lists include checking that all closet doors and dresser doors are in good repair. Program Specialists and compliance will monitor these checklists to ensure that these items are being addressed. |
10/31/2019
| Implemented |
| 6400.73(a) | The railing on the right side of the exterior ramp that leads to the back door was loose. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Request has been submitted to the maintenance contractor for repair. Monthly house check lists include checking all railing and banisters to ensure they are not loose and in good repair. Program specialist and compliance will monitor these checklists to ensure that these items are being addressed. |
10/31/2019
| Implemented |
| 6400.112(a) | No fire drill was held during the month of March 2019. | An unannounced fire drill shall be held at least once a month. | IHRS will ensure that fire drills are completed monthly. Each Program Manager will be responsible ensure that a drill is done before the completion of the month. Furthermore, our compliance department will monitor that drills are being completed in appropriate time frames as outlined by the regulation. |
10/31/2019
| Implemented |
| 6400.112(c) | The exit route used was not documented for the fire drills held during the months of October 2018 and November 2018. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Program Specialist will provide training to staff on proper fire drill record documentation. Drills will be reviewed monthly by program Specialist and compliance department to ensure that all required documentation is listed. |
10/31/2019
| Implemented |
| 6400.112(d) | The fire drill held on 12/31/18 had a documented evacuation time of 4 minutes and 7 seconds, which exceeds the home's extended evacuation time of 4 minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | IHRS will continue to provide fire safety training to staff and clients. Monthly drills will be conducted to ensure that evacuation times are being met. Yearly drills with the Kingston Fire Department chief will be conducted to assess appropriate evacuation times. Program Specialist will train staff on most efficient evacuation procedures to ensure quick and safe evacuation from the home. |
10/31/2019
| Implemented |
| 6400.112(e) | Fire drills were not held during sleeping hours at least every six months. A fire drill was held during sleeping hours on 8/30/18, then not again until 4/01/19. | A fire drill shall be held during sleeping hours at least every 6 months. | IHRS will ensure that fire drills are completed during sleeping ours every 6 months. Each Program Manager will keep a schedule of when asleep fire drill are expected. This will be communicated to the home for execution of the drill. Furthermore, our compliance department will monitor that drills are being completed in appropriate time frames as outlined by the regulation. |
10/31/2019
| Implemented |
| 6400.113(a) | Individual #1 was admitted on 5/15/19 and was not instructed in fire safety training until 6/01/19. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | IHRS will make sure its policy on fire safety is followed. This will be done by ensuring that all individuals are given training on fire safety procedures upon admission. Training to the Program Specialists and direct care staff will occur to ensure that they understand the process of reviewing fire safety upon admission and annually thereafter. In addition, our compliance department will check to ensure that this training is being completed upon admission and annually thereafter. |
10/31/2019
| Implemented |
| 6400.34(a) | Individual #1 was not informed of their rights upon admission to the home. Individual #1 was admitted on 5/15/19 and the individual rights were not reviewed until 6/01/19. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | IHRS will make sure its policy on individual rights followed. This will be done by ensuring that all individuals are given notice of their rights upon admission. Training to the Program Specialists and direct care staff will occur to ensure that they understand the process of reviewing individual rights upon admission and annually thereafter. In addition, our compliance department will check to ensure that this policy is being followed. |
10/31/2019
| Implemented |