| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2390.56 | The water temperature was checked during inspection and did not go above 80 degrees. | A facility shall have hot and cold running water that is suitable for drinking purposes, in bathrooms and kitchen areas. | Work order submitted on 7/31/18, system checked on 8/1/18 and everything was in working order. The issue could not be duplicated. All faucets were checked on 8/1, 8/3, and 8/9; there was hot water at all faucets during each check. The Associate Director checked the faucets several more times during the remainder of August and throughout September. Again, there were no issues noted. Water temperature checks were added to monthly building checklist (attachment #2). Safety committee representative will ensure water checks are completed with monthly building inspection. (Note: Director of Habilitation participated in the August Safety Committee meeting and requested that ¿hot water checks¿ be added to the building inspection form. The Safety Committee chair was absent for this meeting so the Secretary noted the request, but deferred any further action until the Chair was present. On September 12 the Committee voted on the motion to revise the form; the motion carried and the form was revised on October 5. There is no completed form yet to include for documentation, so the blank form is being submitted. See attachment #8.)
While the issue could not be duplicated, we have decided to replace our current water heaters with a high capacity, ¿on demand¿ system to ensure that there are no future issues. The third and final estimate for this process should be received in October and the new system should be installed by mid-November. Engineering Department is obtaining estimates and will schedule/oversee installation of new system. Director of Habilitation will monitor progress monthly until completion. |
10/05/2018
| Implemented |
| 2390.59 | There were no emergency numbers listed. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone | There are no land-line phones in this building. Emergency numbers have been posted at various locations throughout the building¬ (attachment #4). Associate Director will monitor to ensure numbers are still posted during completion of quarterly fire drills. Staff have been retrained regarding this regulation and oriented to the location of each posting (attachment #5). |
08/02/2018
| Implemented |
| 2390.83(a) | The strobe light at exit #8 was inoperable. | There shall be an operable fire alarm that is audible throughout the facility. | Work order submitted 7/31/18, strobe light and bell replaced on 9/21/18 (attachment #9). At the fire alarm test on 9/27, the strobe light was once again not working. Alarm company returned on 9/28, discovered a faulty wire and replaced it. Fire alarm test completed on 10/4. Strobe and bell were operational (attachment #3). Bells and strobes will continue to be monitored during routine alarm checks and fire drills. Associate Director will bear primary responsibility for monitoring during these times. Staff have also been trained to monitor the strobes and bells during alarm tests and fire drills, and to report any issues immediately (attachment #5). |
09/28/2018
| Implemented |