Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.53(b) | There were approximately 16 clear, unlabeled bottles of a sanitizing or cleaning solution in the locked poisons closet. With the bottles, there was a single printed page stating that the product was "MediClean Germicidal Cleaner." Poisonous materials must be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | The 16 bottles were removed from the locked poison closet, emptied and discarded. |
06/03/2022
| Implemented |
2380.87(b) | Two Individuals currently attending the the facility's program are hearing-impaired and there were no strobes or other equipment in the bathrooms to alert the hearing-impaired in the event of a fire. | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. | Two strobes were installed in the bathrooms to alert individuals with hearing impairments in the event of a fire |
07/18/2022
| Implemented |
2380.89(c) | The written fire drill record for the drill that occurred on 4/29/2022 did not record whether the fire alarm was operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative. | The fire drill record for April 29, 2022 was corrected to reflect that the fire alarm was operable. |
06/03/2022
| Implemented |
2380.181(e)(14) | The annual assessment completed on 5/31/2022 for Individual #1 and the annual assessment completed on 9/15/2021 for Individual #2 did not document the Individuals' ability to swim. | The assessment must include the following information: The individual's knowledge of water safety and ability to swim. | The assessments for every active participant were updated to include the individual's ability to swim |
06/21/2022
| Implemented |
2380.21(u) | The facility informed Individual #1 and Individual #2, of their Individual Rights, however, the rights statement used by the facility has not been updated to reflect the Individual Rights in the current Chapter 2380 regulatory chapter. | The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter. | The individual rights were updated to reflect the individual rights in the current chapter 2380 regulator chapter. The updated rights were sent to each individual/family member, signed and returned to the agency. |
08/08/2022
| Implemented |