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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment did not include a completion date; therefore, compliance was unable to be measured. | 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.
| A procedure will be written and staff trained that the Executive Director will disburse the current Licensing Inspection Instrument Scoresheet Facility Chapter 6400 Community Homes annually on or before January 19th which is 6 months prior to the expiration date of the Certificate of Compliance. The inspection instruments will be due from the following positions on or before March 31st: Residential Program Supervisor and Program Specialist. The inspection instrument will be due from the Administrative Officer who completes the Staffing section including the training requirements in Regulation 46 and Staff Health including physicals on or before April 15th which is approximately 3 months prior to the expiration of the Certificate of Compliance. The Executive Director will ensure the deadlines are met and then compile the data into one scoresheet for each residential home on or before April 18th which is 3 months prior to the expiration date. |
10/04/2015
| Implemented |
| 6400.80(a) | The "Smoker's Oasis", cigarette butt receptacle was approximately a third of the way down the ramp in front of the home. In addition, a plastic white chair was on the porch at the top of the ramp. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The "Smoker's Oasis", cigarette butt receptacle will be removed and located to an area that does not cause an obstruction. The white plastic chair will be removed from the porch. A procedure will be written to ensure that all agency staff will be trained in this regulation requirement during orientation with the Fire Safety Training section. All current staff will be trained in this procedure. There may be no items placed on any exits which would deter egress from the building. There will be absolutely no items placed on the floor of any stairways, halls, doorways, passageways and exits from the building. Finally, no doors may be equipped with operable locks which require a key or combination entry to gain egress or permit exit from the building. The outside walkways must be free from ice, snow or any obstructions or hazards. The outside of the building and yard must be well maintained, in good repair and free from unsafe conditions. Staff are to complete a Request for Maintenance if any repairs are required to comply with this regulation. The Residential Program Supervisor responsible for Physical site/Fire Safety inspection will periodically or at least monthly, ensure compliance with Regulation 101, 80 (a) and 80 (b) and document on the appropriate checklist.
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10/04/2015
| Implemented |
| 6400.101 | A cloth "stop" sign approximately one foot wide by four feet long was stretched across the doorway in the front of the home and fastened by Velcro straps approximately four feet from the floor to either side of the doorway. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The cloth stop sign will be removed. A procedure was written that all agency staff will be trained in this regulation requirement during orientation with the Fire Safety Training section. All current staff will be trained in this procedure. There may be no items placed on any exits which would deter egress from the building. There will be absolutely no items placed on the floor of any stairways, halls, doorways, passageways and exits from the building. Finally, no doors may be equipped with operable locks which require a key or combination entry to gain egress or permit exit from the building. The outside walkways must be free from ice, snow or any obstructions or hazards. The outside of the building and yard must be well maintained, in good repair and free from unsafe conditions. Staff are to complete a Request for Maintenance if any repairs are required to comply with this regulation. The Residential Program Supervisor responsible for Physical site/Fire Safety inspection will periodically or at least monthly, ensure compliance with Regulation 101, 80 (a) and 80 (b) and document on the appropriate checklist.
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10/04/2015
| Implemented |
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