| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.88(a) | At the time of inspection, the fire extinguisher located on the wall under the clock on the left side of the program area was not operatable. This fire extinguisher did not read green "calibrated" to an operable level. | There shall be at least one fire extinguisher with a minimum 2-A rating for each floor including the basement. | The fire inspection company was called back to the site to replace the fire extinguisher. |
07/21/2023
| Implemented |
| 2380.111(b) | Individual #1's physical examination was not dated. | The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | Individual #1 went for an updated physical on 7/26/23. Program specialist let team know all information needs to be filled out completely. Upon return of the physical form, program specialist will review for completion of needed information, including dates the physical was completed and signed by the doctor. |
07/26/2023
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 went for an updated physical on 7/26/23. Program specialist let team know all information needs to be filled out completely. Upon return of the physical form, program specialist will review for completion of needed information, including dates the physical was completed and signed by the doctor. |
07/26/2023
| Implemented |
| 2380.113(a) | Staff #1 had a physical examination on 8/27/20 and their next one was completed on 10/25/22. This exceeds the requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Due dates for staff physicals & TB tests are monitored by both HR, and program leadership. Staff are notified 3 months in advance of upcoming due dates. Supervisors will meet with staff to assure needed physicals and TB tests are scheduled. |
07/14/2023
| Implemented |
| 2380.113(c)(2) | Staff #1 had a Tuberculin skin testing with negative results on 8/20/20 and their next one occurred on 10/28/22. This exceeds the requirement. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Due dates for staff physicals & TB tests are monitored by both HR, and program leadership. Staff are notified 3 months in advance of upcoming due dates. Supervisors will meet with staff to assure needed physicals and TB tests are scheduled. |
07/14/2023
| Implemented |
| 2380.173(1)(ii) | Individual #2's record did not include their eye color as this section was left blank on the face sheet form. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | This was corrected and the individual¿s eye color was added to their emergency facesheet. Program Specialist will review all the emergency facesheet to ensure there is no required personal information missing. Updated emergency facesheet attached. |
07/13/2023
| Implemented |
| 2380.181(e)(14) | Individual #2's assessment dated 6/16/23 did not assess their ability to swim. | The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim. | The assessment was corrected and sent to the team for the individual (BL). Program Specialist will review all assessments to ensure this section has the required information. Updated assessment and e-mail to team attached. |
07/13/2023
| Implemented |