| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | At the time of inspection, the first aid kit did not have scissors. The Program Specialist did go to find other first aid kits. Every kit located was missing items under the regulation. Staff was able to combine kits and correct the citation at the time of inspection. A first aid kit must contain all required items. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Program Manager assessed all kits following the inspection and made sure they all met regulatory requirements. All missing items were added to the kits. |
10/31/2022
| Implemented |
| 6400.112(a) | At the time of the inspection there was no fire drills documented for the months of April 2022 and February 2022.
On the date of 5/3/2022 at 4:36pm the drill was not completed due to individual #10 refusing to evacuate.
On the date of 3/28/2022 at 4:15pm the drill was not completed due to individual #10 refusing to evacuate.
In summary there was no fire drill completed for February, March, April and May of 2022. | An unannounced fire drill shall be held at least once a month. | Individual has successfully completed all attempted drills without issue in the last few months. |
11/22/2022
| Implemented |
| 6400.112(d) | The fire drill held on 10/11/2021 at 11:30pm reports that it took 4 minutes and 23 seconds to evacuate. This exceeds the approved time by a fire safety expert. | 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 employe 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. | Program Manager will contact fire safety expert to clarify if an extended evacuation time is necessary and meets safety needs. Program Specialist will also contact a fire safety expert to provide training to all individuals in the home regarding fire safety. |
10/31/2022
| Implemented |
| 6400.112(e) | There was a sleep fire drill documented on 6/11/2022 at the time of 6am. The previous sleep drill was on 10/11/2021 at 11:30pm which exceeds the 6-month time frame. | A fire drill shall be held during sleeping hours at least every 6 months. | Program Manager received individual feedback and training from CEO. Program Manager is required to submit all fire drills to Compliance Department at the end of every month. Requirements of asleep overnight drills reviewed with Program Manager. Training on importance of fire safety provided to Program Manager. Program Manager to provide training to DSP's on the importance of fire drills and fire safety. |
10/31/2022
| Implemented |
| 6400.32(r) | Individual has the right to lock their bedroom door. Individual #6 did not have a lock on his bedroom door. | An individual has the right to lock the individual's bedroom door. | Individual will be asked if they wish to have a lock on their bedroom door. If individual wishes to have a lock, IHRS will provide. IHRS will make sure staff have a key for entry in the case of an emergency. |
10/31/2022
| Implemented |