Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.82(e) | There is no bath mat on second level bath tub. | Bathtubs and showers shall have a nonslip surface or mat. | Corrected same day as inspection. Tub mat was purchased and placed in tub on 12/15/2021. |
01/31/2022
| Implemented |
6400.151(a) | There is no up to date physical exam for Staff #1. The most recent exam is dated May 2018. A physical exam is needed every two years. | 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, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #1 is scheduled for physical exam with occupational health on 2/15/22. Documentation will be provided by the Human Resources Compliance Manager when the physical is completed. |
02/15/2022
| Implemented |
6400.46(a) | There is no fire safety training for Staff #1. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff fire safety training was located for 2020 and 2021. |
12/31/2021
| Implemented |
6400.169(d) | There is no trainer information or recertification date on the Medication Administration training for Staff #1. This information is needed on the annual practicum form. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Medication trainer will conduct a review either in person or virtually with Staff #1 and complete documents accurately. |
05/31/2022
| Implemented |