|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | The kitchen window overlooking the driveway of the home did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | 1. Revised regulation reviewed with all managers via team meeting on 6/12/18.
2. All 6400 Regulatory clarifications published since 9/13 were printed, reviewed and shared with relevant departments.3. Packets were sent to Joe, Fred, Brenda, program specialists on 6/13/18.
4. Back up screens will be purchased for each site. [On 7/10/18, the maintenance team installed custom screen to the kitchen window. Immediately and at least quarterly, a designated staff person shall complete onsite check of all homes to ensure windows, including windows in doors, shall be securely screened. Within 30 days and upon hire, a designated staff person shall educate staff person on the process for requesting repairs or replacement of screens as needed and to monitor throughout the course of their daily duties. (AS 7/17/18)] |
07/01/2018
| Implemented |
| 6400.111(f) | The fire extinguishers in the kitchen, basement, first floor office and second floor of the home were most recently inspected by a fire safety expert in May 2017. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 1. Comprehensive list of all fire extinguishers in all houses to be updated. To include number of extinguishers at each site as well as specific location of each one
(By 6/30/18)2. Managers were provided with a list of the months each house is due for fire extinguishers to be checked (6/12/18)3. Managers will alert IT/Maintenance Director and Program Director if extinguishers have not been inspected with updated tags by the 15th of the month that their home is due (monthly)
4. Managers will review and sign the Fireline invoices and route them to Fred ASAP after the Fireline visit (Upon completion of Fireline inspections)
5. Fred or Kathy will contact Fireline and get them done before the end of the month
(upon notification from houses)
[The fire extinguishers in the kitchen, basement, first floor office and second floor of the home were inspected and dated on 6/6/18. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate the aforementioned staff persons in the aforementioned process. Documentation of training shall be kept. At least quarterly for 1 year, a designated management staff person shall completed an onsite check of all fire extinguisher in all community homes to ensure all fire extinguishers in all community homes are inspected and approved annually by a fire safety expert and the date of the inspection is on the extinguisher. Documentation of checks shall be kept. (AS 7/17/18)] |
06/12/2018
| Implemented |
|
|