| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | At the time of the inspection, the water temperature in the bathroom sink was measured at 122.5. | 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. | This regulation is important because it minimizes the risk that individuals will suffer burns by coming into contact with exposed heat sources.
During the inspection, the water temperature in the bathroom sink was measured at 122.5.
On March 15, 2023, the physical inspection took place that recognized the water temperature being 122.5 degrees. Maintenance was contacted and adjusted the water temperature to ensure that it did not exceed 120 degrees. For the remainder of the month, the program staff are checking the water temperature daily at all accessible sources to ensure it does not exceed 120 degrees. See Attachment #11 for proof of the water being adjusted and tracking of ongoing water temperatures for the month. |
03/29/2023
| Implemented |
| 6400.104 | During the calendar year, Individual #1 has stayed at this respite home for more than 31 calendar days. No notification letter was sent to the fire department with Individual #1's information. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| This regulation is important because it provides advance notice to first responders to help evacuate individuals quickly in the event of an emergency.
At the time of the inspection, Individual #1 stayed at the Respite home for more than 31 calendar days and there was no notification letter sent to the fire department with his information.
This occurred because the Program Specialist and Assistant Director failed to adhere to this regulation.
Immediately following the inspection, a fire letter was sent to the local fire department with information pertaining to Individual #1. See Attachment #12. |
03/29/2023
| Implemented |
| 6400.113(a) | During the calendar year, Individual #1 has stayed at this respite home for more than 31 calendar days. No documentation was provided verifying that Individual #1 received fire safety training specific to this home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | This regulation is important because it ensures individuals know the necessary measures to take in the event of an emergency.
During the inspection, Individual #1 did not have a fire safety training specific to the Respite home. Individual #1 stayed at this home for more than 31 calendar days.
This occurred because the Program Specialist and Assistant Director failed to adhere to this regulation.
Immediately following the inspection, Individual #1 received fire safety training specific to the Respite home. See Attachment #13. |
03/29/2023
| Implemented |
| 6400.32(t) | At the time of the inspection, there were snack foods that were locked and not accessible to the individuals. | An individual has the right to access food at any time. | This regulation is important because it promotes self-direction, choice, and control.
At the time of the inspection, there was snack food locked and not accessible to the individuals.
This occurred because the Program Supervisor and Program Specialist failed to ensure that all food was accessible to the individuals.
Immediately following the recognition of snacks being locked, the Program Supervisor moved all the snacks to an unlocked area, ensuring they were accessible to the individuals. See attachment #10.
On 3/20/2023, Program Specialists were retrained on the individual's rights to have access to food. |
03/29/2023
| Implemented |