| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | The bedroom for individual #1 had a closet with cookies and Gold Bond moisturizer which had on its label, "if ingested call poison control." | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Residential Site Supervisors responsible for the sites as well as the Assistant Directors on 3/6/19 about the importance of keeping poisonous materials away from food. The Residential Site Supervisor will be responsible to assure that all poisonous materials are placed in a separate area away from food. The CLA Site Checklist is completed on a weekly basis by the Residential Site Supervisor to assure that residents stay safe by having all poisons properly secured away from food. To further assure regulatory compliance, Assistant Directors will conduct unannounced quarterly site visits that will be monitored by the CLA Director.This citation was resolved immediately on 2/27/19 while licensors were still on site. The Residential Site Supervisor removed the cookies from the closet in the resident's room and placed it in a secure location away from poisons. |
02/27/2019
| Implemented |
| 6400.64(a) | The baking pan was found rusted and had partly baked on food. | Clean and sanitary conditions shall be maintained in the home. | Based on the licensing review of February 26-27, 2019, the CLA Director retrained the Residential Site Supervisors responsible for the sites as well as the Assistant Directors on 3/6/19 about the importance maintaining clean and sanitary conditions at all sites. It is the responsibility of the Residential Site Supervisor to assure that each household is in good repair on a weekly basis. A CLA Site Checklist is completed on a weekly basis by the Residential Site Supervisor to assure that all surfaces are clean and in good repair. When items are not clean, worn or broken, the Residential Site Supervisor will take corrective action to assure compliance with this regulation. To further assure regulatory compliance, Assistant Directors will conduct unannounced quarterly site visits that will be monitored by the CLA Director. This citation was resolved on 2/28/19, the same day the licensor was at the site, when staff degreased and cleaned the kitchen exhaust. |
02/28/2019
| Implemented |
| 6400.111(e) | The kitchen fire extinguisher was hung on a curved hook and could not be readily detached for use. | A fire extinguisher shall be accessible to staff persons and individuals. | Based on the licensing review of February 26-27, 2019, the CLA Director informed the Facilities' Director of the improperly hung fire extinguisher and the need to ensure that all other fire extinguishers are accessible and in compliance. Additionally, The CLA Director retrained the Residential Site Supervisors responsible for the sites as well as the Assistant Directors on 3/6/19 about the importance of ensuring that all fire extinguishers are maintained in manner accessible to staff and individuals. It is the responsibility of the Residential Site Supervisor to assure that each household is in good repair on a weekly basis. A CLA Site Checklist is completed on a weekly basis by the Residential Site Supervisor to assure regulatory compliance. When a fire extinguisher needs to be remounted for accessibility, the Residential Site Supervisor will take corrective action to assure compliance with this regulation. To further assure regulatory compliance, Assistant Directors will conduct unannounced quarterly site visits that will be monitored by the CLA Director. This citation was resolved on 3/5/19 when the fire extinguisher was relocated and hung with a fire extinguisher specific hook for ease of accessibility. All PATH CLA sites have been checked to assure that no other fire extinguishers are mounted in a way that impacts their accessibility |
03/05/2019
| Implemented |