Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | Surfaces shall be in good repair. At the time of inspection, the individual #1 bedroom dresser had broken handles and was missing a drawer. | Floors, walls, ceilings and other surfaces shall be in good repair. | Dresser was replaced. IHRS will conduct audit of all locations bedroom furniture to ensure no other items need to be replaced. |
12/31/2023
| Implemented |
6400.67(b) | Surfaces shall be free from hazards. At the time of the inspection the dryer had a golf ball size amount of lint in the lint trap. This creates a fire hazard when not cleaned out regularly. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Dryer was cleaned immediately. IHRS often issues memos and correspondence regarding cleaning lint from the dryer. This is also covered in fire safety training. Individual follow-up will occur with house staff. |
12/31/2023
| Implemented |
6400.81(k)(6) | The individual bedrooms shall have a mirror. Both individual #2 and #3 did not have mirrors in their room at the time of inspection. | In bedrooms, each individual shall have the following: A mirror. | Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Mirror was purchased and placed in individual #2 and #3¿s bedroom. |
12/31/2023
| Implemented |
6400.82(e) | The first bathroom containing the stand up shower did not have a non slip mat. | Bathtubs and showers shall have a nonslip surface or mat. | Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Bathtub/shower mat was purchased and placed in the home. |
12/31/2023
| Implemented |
6400.112(a) | There was no documentation to reflect that a fire drill occurred during the months of February, March, July, August or September of 2023. A fire drill shall be conducted every month. | An unannounced fire drill shall be held at least once a month. | Program Manager and DSP's working at all locations will be re-trained in the above mentioned regulation. Fire drill was completed. Fire drills will be conducted on a monthly basis. |
12/31/2023
| Implemented |
6400.112(e) | A sleep drill must be held every 6 months. The agency conducted a fire drill on 5.23.23 at 9:46pm which they documented was a sleep drill. However, the comment section of this drill reflects that not all individuals were sleeping. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Manager's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (c). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. |
12/31/2023
| Implemented |