| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed 8/13/15; the agency's current certificate of compliance is from 9/1/15 to 9/1/16. | 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.
| The Office Coordinator has an event scheduled in her Outlook calendar starting in March where she can send out the self-assessments that will then be due by April 31. The ID/D Manager will track when they are received to ensure they are completed in a timely manner. |
03/26/2016
| Implemented |
| 6400.71 | The telephone number for the poison control center was not on or by the telephone in the living room of the home. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The telephone numbers were attached to the phone on 2.11.16. Supervisors and Lead DSP¿s will be checked and or replaced on a monthly basis and also quarterly on the Quarterly Home Safety Checklist which are collected and reviewed by the ID/D Manager. [Immediately, all telephones in all community homes will be checked to ensure all required numbers are on and by each telephone with an outside line. Documentation of the monthly and quarterly checks and reviews shall be kept. (AS 4/20/16)] |
03/26/2016
| Implemented |
| 6400.110(a) | The smoke detector in the basement of the home was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The smoke detector was replaced on 2.12.16. All Smoke detectors are checked on a monthly basis by DSP¿s and then again by supervisors. They are also checked quarterly on the Quarterly Home Safety Checklist, which is then reviewed by the Manager of ID/D Residential Services.
Written Procedure in the event a smoke detector or fire alarm is inoperative.
1. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative.
2. Fire System Safety Checks are documented on MYCS¿s current fire drill form monthly to ensure all smoke detectors are operative.
3. In the event, a smoke detector was found inoperative. The battery would be replaced immediately upon discovery and tested to determine if in proper working order.
4. If smoke detector is still inoperative after replacing batteries, then notification for repair shall be made within 24 hours from time of discovery and repairs completed from time smoke detector or alarm was found inoperative
5. If any fire system is inoperable, staff must do fire checks every hour throughout the site until corrected. Documentation of failure and system checks will be completed during time of repair or replacement of smoke detector(s) or alarm, and the documentation attached to monthly fire drill to include date, time, site check, and staff signature for each hourly check. [Immediately, designated staff person will check all smoke detectors at all community homes to ensure all smoke detectors are operable. ID/D Manager will train the designated staff persons who are completing the aforementioned policies and procedures to ensure all community homes have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of all smoke detector checks and other aforementioned documentation will be reviewed at least quarterly by the ID/D Manager to ensure completion and that all smoke detectors at all community homes to ensure all smoke detectors are operable. (AS 4/20/16)] |
03/26/2016
| Implemented |