| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(a) | The home did not have a minimum of one operable automatic smoke detector on each floor, including attic. The smoke detector located in the attic was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The smoke detectors at the home were replaced with interconnected wireless smoke detectors on 12/8/23. |
12/08/2023
| Implemented |
| 6400.110(e) | The home has three floors including the basement and attic. The home did not contain interconnected smoke alarms or an interconnected fire alarm system. | 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 smoke detectors at the home were replaced with interconnected wireless smoke detectors on 12/8/23. |
12/08/2023
| Implemented |
| 6400.111(a) | There were not operable fire extinguishers with a minimum 2-A rating for each floor, including the basement and attic. Fire extinguishers in the home were rated 1A. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Fire extinguishers in the home were replaced with Fire Extinguishers that were compliant with the regulation on 12/8/23. |
12/08/2023
| Implemented |
| 6400.111(c) | There was not a fire extinguisher with a minimum 2A-10BC rating shall be located in the kitchen. The fire extinguisher located in the kitchen was rated 1A. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire extinguishers in the home were replaced with Fire Extinguishers that were compliant with the regulation 12/8/23. |
12/08/2023
| Implemented |
| 6400.112(d) | Individuals did not evacuate the entire building un under 2 ½ minutes during a fire drill conducted on 10/4/23 at 2AM. The documented evacuation time was 202.15 seconds. This is 3 minutes and 36 second. | 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. | It was determined that the form was completed incorrectly by the staff who conducted the fire drill. A fire drill was conducted and was documented properly. |
01/12/2024
| Implemented |
| 6400.165(c) | Medications are not prescribed in writing by an authorized prescribed. There were three packets of aspirin, 1 packet of non-aspirin and 3 packets of ibuprofen located in the first aid kit of the home. These medications are not prescribed to the individual residing in the home. | A prescription medication shall be administered as prescribed. | Unprescribed medications were discarded immediately upon discovery. |
12/07/2023
| Implemented |