| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(f) | Staff #1 received fire safety training on 10/7/14 and not again until 10/21/15. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Regulation 6400.46f was reviewed with the Program Manager and House Managers on 7/28/2015 by the Assistant Director (Attachment #11). The Program Manager will arrange for Fire Safety Training be offered every 6 months to ensure that staff do not miss the annual training requirement. Fire Safety Training will occur in September and March at all houses. |
07/28/2016
| Implemented |
| 6400.62(a) | Individual #1 is not safe around poisons. Toothpaste was unlocked in the bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Regulation 6400.62(a) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #9) The toothpaste for individual #1 will be locked in the locked cabinet where his medications are stored (Attachment #10). We would like to have further discussion on this cite as we feel it takes away some of the individual's independence and goes against the spirit of everyday lives. |
07/19/2016
| Implemented |
| 6400.67(a) | The refrigerator had a large rust spot, approximately 4 inches by 12 inches, under the ice and water dispenser. | Floors, walls, ceilings and other surfaces shall be in good repair. | Regulation 6400.67(a) was reviewed with the Program Manager and House Managers on 7/28/2016 by the Assistant Director (Attachment #7). The maintenance director repaired the large rust spot under the ice and water dispenser as a temporary fix until the refrigerator can be replaced (Attachment #8). |
07/28/2016
| Implemented |
| 6400.101 | The egress door leading from the garage to the back yard was blocked with a snow blower. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Regulation 6400.101 was reviewed with the Program Manager and House Managers on 7/28/2016 by the Assistant Director (Attachment #5). The snow blower was relocated to another area of the garage and is no longer blocking the garage door to the back yard (Attachment #6). |
07/28/2016
| Implemented |
| 6400.106 | The furnace was cleaned and inspected on 7/22/14 and not again until 12/31/15. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Regulation 6400.106 was reviewed with the Program Manager and House Mangers on 7/19/2016 by the Assistant Director (Attachment #3). The furnace cleaning was conducted annually, on 1/27/2015 and on 12/31/2015 (Attachment #4 and Attachment #4a). |
07/19/2016
| Implemented |
| 6400.145(1) | The emergency medical plan did not include the location of the hospital to be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Regulation 6400.145(1) was reviewed with the Program Manager and House Managers on 7/19/2016 by the Assistant Director (Attachment #1). The emergency medical plan was updated to include the hospital to be used in an emergency (Attachment #2). The CHS Program Manager is responsible for ensuring the plan is posted in the home and will monitor monthly to ensure on-going compliance. |
07/19/2016
| Implemented |