Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.63(a) | On 8/2/2/23, the hot water temperatures at the sink located in the hallway bathroom measured 124.1 Degrees Fahrenheit at 10:30 AM and 123.2 Degrees Fahrenheit at 10:33 AM at the kitchen sink. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The hot water tank was adjusted immediately. The water temperate was tested three times and did not exceed 120 Degrees Fahrenheit. |
09/01/2023
| Implemented |
6400.112(d) | The fire drill completed on 10/26/22 had an evacuation time of 3 minutes, and the fire drill conducted on 1/16/23 had an evacuation time of 3 minutes and 45 seconds. This home does not have an approved extended evacuation time. | 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. | All fire drills are compliant currently. Fire drills will be conducted monthly, and individuals shall be able to evacuate within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. |
09/01/2023
| Implemented |
6400.181(e)(4) | Individual #1's assessment completed on 12/14/22 states the following contradictory information in the domain of supervision: they are unable to be left unsupervised for less than 4 hours but yet does not require 24-hour supervision. | The assessment must include the following information: The individual's need for supervision.
| Individual assessment was corrected to reflect proper supervision guidelines. All other individual assessments were checked for accurate information in comparison to the Individual Support Plan. |
09/01/2023
| Implemented |
6400.181(e)(14) | Individual #1's assessment completed on 12/14/22 indicates the following contradictory information in the skill domain of water safety: they are independent with water safety, yet they do not know or follow basic water safety rules. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Individual assessment was corrected to eliminate conflicting information and reflect proper water safety guidelines. All other individual assessments were checked for accurate information in comparison to the Individual Support Plan. |
09/01/2023
| Implemented |
6400.32(n) | On 8/22/23, the only phone located in the home was located on the table in the locked kitchen and inaccessible to the individuals. | An individual has the right to unrestricted and private access to telecommunications. | The phone was immediately relocated to the common area of the home where it's easily accessible to all of the individuals in the home. |
09/01/2023
| Implemented |