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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment provided by the agency, dated 06/23/21, did not address the following regulations: 6400.191-210b3, 6400.231-245d, 6400.261a-263, and 6400.271(1)-275. | 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.
| In response to this violation of 6400.15(a) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Effective immediately, the program specialists of the McGuire Memorial community home program will be trained to utilize the ¿self-assessment licensing inspection instrument¿ that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. The program specialists will be responsible for completing these self-assessments, including marking ¿NA¿ for any areas that do not apply to the house that they are assessing. Once completed, these self-assessment forms will be submitted to the Director and Assistant Director of Community Homes for their review. These self-assessments will occur within 3 to 6 months prior to the expiration date of the agency¿s current certificate of compliance. [Training on Self-Assessments, dated 3/29/22, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS]. |
03/09/2022
| Implemented |
| 6400.112(d) | The fire drill conducted in the home on 06/26/21 had an evacuation time of 2 minutes 33 seconds; the fire drill conducted in the home on 12/11/21 had an evacuation time of 3 minutes 16 seconds; and the fire drill conducted on 01/27/22 had an evacuation time of 2 minutes 50 seconds. No documentation of an extended evacuation time written by a fire safety expert within the past year was provided for the inspection conducted 02/08/22 to 02/10/22. | 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. | In response to this violation of 6400.112(d) discovered during the licensing inspection for the McGuire Memorial Community Home program held from 2/8 to 2/10 of 2022, the plan of correction is as follows: Starting immediately, the house managers of the McGuire Memorial community home program will be trained that they are required to hold and document an unannounced fire drill every month at each house that is currently occupied and a part of our program. These fire drills must have an evacuation time of no more than 2 minutes and 30 seconds. In the event that the conducted drill does exceed 2 minutes and 30 seconds, the drill will be repeated within the same calendar month. [Training on fire drills, including maximum evacuation time, occurring on various dates, received on 4/4/22 and reviewed on 4/19/22 by HDKP, HSLS.] |
03/09/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The side lights located on the outside of the house on the right side did not contain lightbulbs and posed a safety hazard. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| McGuire Memorial will ensure that all light fixtures are in working order and have light bulbs and light bulbs that are not burnt out. The Program Specialist will ensure that the House Manager completes monthly house inspections, which includes checking all light bulbs and light fixtures to ensure they are in working order. The Program Specialist will be responsible to ensure that all staff are in-serviced to immediately change light bulbs that are burned out or to complete a maintenance request for any light bulb that is not reachable. The Program Specialists and House Managers will check the lights when they are at the home and direct the staff to change bulbs that are within staff¿s reach or complete a maintenance request to have a light bulb changed. The Director/Assistant Director will conduct quarterly house inspection which includes checking that all light fixtures and light bulbs in the home are in working order. |
01/16/2015
| Implemented |
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