| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The blinds located in the entrance windows are damaged and need to be replaced. | Floors, walls, ceilings and other surfaces shall be in good repair. | All blinds located in the entrance windows have been replaced. Our Program Specialist shall do quarterly inspections at this home to ensure that all blinds are in good working condition and if there is a need for replacement, they will be replaced before the next ODP inspections to remain in compliance for this regulation. |
10/26/2022
| Implemented |
| 6400.68(b) | The hot water measured 130.1*F in the bathtub. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Our Program Specialist and our maintenance person went out and made adjustments to the hot water heater tank. The adjustment made enable the thermometer reading for the bathtub and or shower to have readings of 120 degrees F. Our maintenance person and Program Specialist will do monthly documented checks on the hot water temperature in the shower and or bathtub and make all necessary adjustments to the hot water temperature. There will be a check list with hot water temperature monthly readings |
10/26/2022
| Implemented |
| 6400.101 | The back door of the home was not able to be opened as staff does not have the key to access the locked door. This door is stated on fire drills to be used in case of a fire or emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The lock to the back door of the home has been changed and it is accessible to staff and consumer. This door has been used to go in and out during consumer barbeque. In addition, this door has been used for fire drills with the consumer and staff participating. |
10/26/2022
| Implemented |
| 6400.110(e) | The home has three stories which include a basement the smoke detectors are not interconnected and is not audible throughout the house. | 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. | The maintenance person and Staff Supervisor have installed three new smoke detector that are interconnected electronically, one in the basement, first floor and second floor. This will ensure in the case of fire all floors in this building will be alerted. |
10/26/2022
| Implemented |
| 6400.112(d) | The following fire drills extended past 2.5 minutes must be documented and re-tested to ensure consumers can safely evacuate.
2/23, 3/24, 4/29, 5/29-fire drills 3 mins long no new drill taken | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | LSHS staff have continued to do fire drills and participants were able to evacuate the entire building at the designated safe area that was designated by the Fire Safety expert, the back yard of the building. The Staff and consumer were able to exit the entire building under 2 1/2 minutes during fire drills. |
10/26/2022
| Implemented |