Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.66 | The light in the attic was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. |
11/30/2018
| Implemented |
6400.80(b) | A broken chair and a replacement dining table/chairs were stored on the back porch of the home since August 2018. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. |
11/30/2018
| Implemented |
6400.110(e) | The attic smoke detector was not checked monthly, as reported by a direct care staff. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. |
11/30/2018
| Implemented |