| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | Every program room had a cabinet which stored their poisons. Several of their cabinets used what appeared to be a child lock to keep the poisons secure. However, this type of lock was able to be opened by just pinching the sides of the lock to open the device and have full access to the poisons. This lock did not secure the poisons as the regulation requires. The poisons were easily accessible with the lock that was being utilized. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | Child safety locks removed and replaced with pad locks. |
11/28/2023
| Implemented |
| 2380.91(a) | Individual #2 did not have proper documentation of the annual fire safety training. There was a fire safety form which was signed and dated 8/4/23 by the individual. However, the form was not properly filled out. The areas of the training were not filled in on this form and it is unable to determine if the topics were covered with this individual. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. | Individual #2 fire safety form was completed on 11/16/23. |
11/16/2023
| Implemented |
| 2380.111(a) | Individual #1 had a physical on 9/19/22 and then not again until 10/6/23. This exceeds the annual requirement. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 completed his physical on 11/17/23. |
11/17/2023
| Implemented |
| 2380.111(c)(5) | Individual #1 did not have TB testing with negative results on his physical exam. Staff report that he has reactions to the TB tests. A recommendation to have the QuantiFERON test completed to meet the requirement of this regulation was made. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Individual #1 had the Quantiferon TB blood test completed on 11/29/23 with a negative result. |
11/29/2023
| Implemented |