|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.65 | The upstairs bathroom did not have fan and the only window in the bathroom was unable to be opened; therefore, the bathroom lacked ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Issue was immediately addressed during licensing visit. Window was opened Attachment # 21. However, window was unable to stay open without being propped. Program director sent email to OPS, that the window be repaired/replaced Attachment # 22. New window was ordered Attachment # 23. Due to issues related to Covid 19 pandemic and supply chain issues, window have yet to be installed at the time of POC. Documentation will be provided once window arise installed. To prevent future occurrences: Community Home Review sheet was updated to include ensuring that windows freely open and are equipped with screens Attachment # 24 |
01/10/2022
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | There was an egress in individual #2's bedroom that was blocked by a fabric shade. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Program manager removed the fabric shade and replaced it with a shortened curtain, ensuring privacy for the individual in the bedroom (attachment # 42). To ensure compliance that stairway, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly (attachment #3). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure no egresses are blocked, and conditions meet regulations (attachment #4). Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. |
03/29/2019
| Implemented |
| 6400.110(e) | The fire alarm for the home could only be heard in the basement of the home. There were no audible sirens beyond that point. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Fire watch log was immediately instituted (attachment #39). Kartman fire alarm company was notified within 24 hours and scheduled to fix system. System was repaired 3/29/2018, within 48 hours of the time the alarm was found to be inoperative (attachment #40). In order to ensure compliance that at least one smoke detector on each floor of the home is interconnected and audible throughout the home, the fire alarm system will be inspected annually. In addition, monthly fire drills will occur at the home (attachment #41). If the alarm is found to be inoperative, a fire watch log will immediately be instituted. Program manager will be notified and fire alarm company will be immediately notified to repair system as needed. If repairs are not made within 48 hours of the time the system is found to be inoperative, emergency relocation will occur |
03/29/2019
| Implemented |
| 6400.163(a) | There were packets of Tylenol in the first aid kit. | Prescription medications shall only be used by the individual for whom the medication was prescribed. | The Tylenol was immediately removed from the first aid kit and appropriately disposed (attachment #38). To ensure compliance that prescription medications are used only by the individual for whom the medication was prescribed, CHS Co-Directors sent a memo to program managers, instructing them to immediately check all current first aid kits to ensure that no Tylenol or other medication was in the kits, and to always check newly purchased first aid kits to ensure that Tylenol or other medication was not packaged in the kits and to appropriately disposed of any such medication if found (attachment #22). Going forward, program managers will visit all their sites at least weekly, and check the contents of the first aid kits (attachment #23), which will be submitted to co-directors biweekly. Any issues of noncompliance will be immediately addressed. |
03/29/2019
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The 2nd floor bathroom has mildew on the perimeter on the wall tile and the bathtub. | Clean and sanitary conditions shall be maintained in the home. | The 2nd floor bathroom at 6710 Ridge Ave. had mildew on the perimeter on the wall tile and the bathtub. This was repaired by Interact's maintenance department on 7/10/14. At that time, all mildew was removed from the perimeter on the wall tile and the bathtub was re-caulked and the bedroom door was painted. Pictures will be provided as supporting documentation to show repairs were made. Interact will assure that clean and sanitary conditions are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Site Review Checklist which will be submitted to Co-Directors biweekly. Additionally, the CHS Co- Directors, Assistant Director and Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the Program Manager and/or Operations as needed. See attachment #6 |
07/10/2014
| Implemented |
|
|