| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The lazy Susan cabinet in the kitchen is broken and unable to turn. | Floors, walls, ceilings and other surfaces shall be in good repair. | Who: Director of Services, Assistant Director of Services, RPS and all staff in residential program. Maintenance Department will complete repairs when necessary.
What: ensure that all floors, walls, ceilings and other surfaces are in good repair. A maintenance request was completed prior to licensing and has been fixed.
How: 1. Administrative Regulation Monitoring Form was updated ¿ Check all kitchen cabinets to ensure that they are in good condition 2. Retraining - RPS agenda ¿ reviewed information with Residential Program about ensuring that all floors, walls, ceilings and other surfaces are in good repair and to submit a maintenance request when an item is out of compliance. RPS will review RPS agenda with their staff.
When: 1. Administrative Regulation Monitoring Form will be completed at least twice during any quarter (July/August/September, October/November/December, etc.). 2. Residential Program Supervisor and staff ¿ ongoing, as those staff are in the home on a daily basis.
Attachments:
¿ Updated and completed Administration Regulation Monitoring Form (completed by DOS on 9/13/2017). (#6 ¿ 9 pages)
¿ RPS agenda showing information was reviewed with RPS. (#7 ¿ 4 pages)
¿ Copy of maintenance request and documentation that repairs were made. (#23) |
09/13/2017
| Implemented |
| 6400.67(b) | The wooden step that is off of the side, back porch door is not secure. The step wobbles and has an inch space between the boards on top which move when stepped on. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Who: Director of Services, Assistant Director of Services, RPS and all staff in residential program. Maintenance Department will complete repairs when necessary.
What: ensure that all floors, walls, ceilings and other surfaces are in good repair. Steps were repaired.
How: 1. Administrative Regulation Monitoring Form was updated ¿ Ensure all outside stairs are secure, especially wooden stairs. 2. Retraining - RPS agenda ¿ reviewed information with Residential Program about ensuring that all floors, walls, ceilings and other surfaces are in good repair and to submit a maintenance request when an item is out of compliance. RPS will review RPS agenda with their staff.
When: 1. Administrative Regulation Monitoring Form will be completed at least twice during any quarter (July/August/September, October/November/December, etc.). 2. Residential Program Supervisor and staff ¿ ongoing, as those staff are in the home on a daily basis.
Attachments:
¿ Updated and completed Administration Regulation Monitoring Form (completed by DOS on 9/13/2017). (#6 ¿ 9 pages)
¿
¿ RPS agenda showing information was reviewed with RPS. (#7 ¿ 4 pages)
¿ Copy of maintenance request and documentation showing repairs were made. (#24) |
09/13/2017
| Implemented |
| 6400.104 | Repeat 7/12/16 The fire notification letter dated 9/2/16 indicated that Individual #1 only required verbal assistance to evacuate in the event of a fire. It was indicated on the fire drill log that Individual #1 did require physical assistance to evacuate during a fire drill on one occasion. | 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.
| Who: Assistant Director of Services and Assistant Program Coordinator
What: ensure that the letter to the fire department is accurate regarding. All 14 homes records were checked to ensure compliance.
How: Updated fire safety letter for this home. All 14 homes records were checked to ensure compliance. Additionally, a statement was added to each letter, stating that the individuals may require additional assistance including verbal prompts, visual/ASL signs, physical assistance or total assistance depending upon the situation or circumstance (real emergency).
The APC who reviews the fire drills and tracks the information on a monthly basis, you will now have to review all fire drill letters on a semi-annual basis to ensure that all fire letters are still accurate. These additional reviews will be completed in August and February of each year. This semi-annual review does not remove the responsibility of updating the letters on an ongoing basis in the event that an individual moves into/out of the program, an individual¿s room is changed or there is a medical/physical change to the individual
When: Ongoing and semi-annual review in August and February of each year
Attachments:
¿ Letter to APC about semi-annual review and duties of updating the fire notification letter. (#21)
¿ Copy of updated fire safety letter. (#22 ¿ 5 pages) |
09/13/2017
| Implemented |
| 6400.110(c) | Individual #1 utilizes alone time to smoke in the garage. The garage is not equipped with a smoke detector. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | Who: Assistant Director of Services
What: Completed a maintenance request to have a strobe light/smoke detector installed in the garage.
How: Hire contractor to complete needed work. Additionally, all other homes were checked to ensure that there is a smoke detector in common areas or hallways. Work for a smoke detector/strobe light will also be completed at the 2 homes in which a recommendation was made. Additionally, all other properties were checked to ensure compliance with this regulations.
When: Work will be completed within 2 weeks of the maintenance staff requesting the work.
Attachments:
¿ Copies of maintenance requests showing work will be completed. (#20 ¿ 2 pages)
¿ Additional paperwork will be forwarded to ODP when work has been completed. |
09/30/2017
| Implemented |