Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.61 | At the time of the 3/2/22 inspection, there was no telephone easily accessible to staff persons or individuals. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | A noncoin-operated telephone has been added to the main space of the facility, so individuals and staff persons have access to it. Emergency numbers have been posted on the telephone as well. Please see attachments 1-4. |
03/21/2022
| Implemented |
2380.62 | At the time of the 3/2/22 inspection, there were no emergency numbers posted. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line. | A noncoin-operated telephone has been added to the main space of the facility, so individuals and staff persons have access to it. Emergency numbers have been posted on the telephone as well. Please see attachment 2 and 4 for the phone numbers listed on the back of the phone. |
03/21/2022
| Implemented |
2380.70(a) | At the time of the 3/2/22 inspection, there was no partition or privacy screen separating the first aid area from program areas. | The facility shall have a first aid area that is separated by partition or privacy screen from program areas. | Partitions were purchased on 3/9/22 and will be installed as soon as it arrives. Please see attachment 5 for receipt for partition items. |
03/21/2022
| Implemented |
2380.111(c)(4) | Individual #1 did not have a vision or hearing exam at their 9/21/21 annual physical examination. The physical examination form stated, "could not check" and "could not be tested." | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The program specialist reached out to individual #1's PCP a few times to get a note stating what happened during the visit whether the Individual refused and was educated on it or if the doctor had to defer the vision and hearing tests and why. They are waiting to get a note from the doctor as the doctor has been out of office, but in the meantime sent a note on 3/21/22 that they have document the need for a note and that the program specialist has reached out to the PCP. Please see attachment 6. |
03/21/2022
| Implemented |
2380.177 | Individual #2's release of information is not signed by their legal guardian. | Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | The release of information form was signed by individual #2's legal guardian and individual #2 on 3/9/22. Please see attachment 7 and 8 for individual rights and release of information signed by the individual and their legal guardian. |
03/21/2022
| Implemented |
2380.129(a) | Staff person #1's medication administration training recertification that was due 9/23/21 was not completed correctly. Staff person #1 has been administering medications without properly completing course renewal requirements. | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration). | Staff person #1 stopped giving medications and will be retrained by completing the Medication Administration Train the Trainer course. Please see attachment 9 displaying the my ODP screen where staff person #1 signed up for the Med Admin Train the Trainer course and it is awaiting payment. |
03/21/2022
| Implemented |