| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.61 | The door leading to the outside in the back corner of the cultural center work space was unable to be closed and opened completely. | Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards. | The door leading outside in the back corner of the Cultural Arts program was found to be damaged and unable to close completely. The Director of facilities addressed this issue immediately and fixed the door on the same day of the inspection, 1/11/2023 (Attachment#1). |
01/11/2023
| Implemented |
| 2390.101 | Individual #1 became Covid positive in 2022 and was out of program from 8/3/22 until 8/12/22. There was no documentation showing that it was clear to return to work. | Staff, clients or volunteers with symptoms of a communicable disease of a serious nature, such as strep throat, conjunctivitis, tuberculosis or other medical problems which might interfere with the health of others as determined by a physician, are not permitted to be present at the facility, without written authorization from a licensed physician. | Individual #1 tested positive for Covid-19 and stayed home for the duration of their quarantine, 8/3/22 through 8/12/2022 in accordance with the CDC and SpArc¿s Covid-19 policy. In accordance with 2390.101, SpArc updated the SpArc Services Covid-19 plan to include the requirement of a doctor's note to return to the program after a person tests positive for Covid-19 and completes their quarantine (Attachment#2). |
01/12/2023
| Implemented |
| 2390.124(3) | Individual #2's record contained a data sheet where the physicians name area was left blank. | Each client's record must include the following information: The name and telephone number of a physician or source of health care. | During the inspection it was found that individual #2 did not have a physician¿s name on their face sheet. This was a printing error as the physician¿s name and contact was listed in the digital record, but had not printed. During the inspection the updated face sheet with the correct information was sent to the inspector on 1/11/2023 (Attachment#3). |
01/11/2023
| Implemented |
| 2390.21(a) | The client rights form has not been updated to include the new regulatory requirements. | An individual may not be deprived of rights as provided under subsections (b) - (q). | During the inspection it was found that the participants rights form had not been updated to include the new regulatory requirements. The Participant Rights document was updated on 1/23/2023 and shared with program specialists on 1/27/2023 (Attachment#5). Program Specialists were expected to meet the participants on their caseloads, read and explain their rights, have the program participants sign the new participants rights form, and send home copies of the new form to the participants' families and/or caregivers (Attachment#6). |
01/23/2023
| Implemented |