Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.73(a) | Repeat - 03/26/15-The basement stairs leading to the exterior door did not have a handrail. Attic staircase did not have a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Sunset Support Services maintenance personal will build hand railings to code on the attic and basement stairways. |
02/15/2017
| Implemented |
6400.103 | The written evacuation procedure did not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The CEO will implement and ensure that an emergency evacuation plan will be written and will include individual and staffing responsibilities. As well as transportation, emergency shelter location to comply with the POC. The CEO will be responsible to implement and train staff and individuals to know their responsibilities. |
02/15/2017
| Implemented |
6400.104 | No current written notification to the local fire department was contained in the record. | 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.
| Sunset Support services has contacted the chief of the local fire dept. to require an official version of said document in order to meet the necessary guidelines set forth for this particular POC |
02/15/2017
| Implemented |
6400.145(3) | The emergency staffing procedure was not included on the emergency medical plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | The CEO will be responsible in identifying staff members to report to work or remain during extended periods |
02/15/2017
| Implemented |