Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.59(b) | The hot water temperature was measured at 134.2 degrees Fahrenheit in the bathroom sink. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The water temp in the bathrooms will be adjusted to no higher than 120 degrees fahrenheit.
Water temp will be checked monthly. |
02/15/2019
| Implemented |
2380.61 | There was no landline telephone in the facility. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | A landline phone will be installed on the premises that will be accessible to individuals and staff.
The landline will remain operable at all times |
02/15/2019
| Implemented |
2380.62 | Emergency telephone numbers were not posted in the facility. | 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. | We will post the numbers of the local police department, ambulance, and poison control center by each telephone in the facility with an outside line.
The numbers will be checked and updated quarterly. |
02/15/2019
| Implemented |
2380.65 | The exterior steps leading to the front and rear entrances did not have a non-skid surface. | Interior stairs and outside steps shall have a nonskid surface. | All interior and exterior step will have nonskid surfaces.
The skids will be checked monthly for security. |
02/15/2019
| Implemented |
2380.68 | There was no designated space for hanging coats and storing personal belongings. | Space shall be provided for hanging hats and coats and storing personal belongings. | We will install pegs in which to hang all hats and coats. We will also provide storage bins/cubbys in which to store person belongings.
We will make monthly maintenance checks to ensure pegs and storage bins and/or cubbys are in good working order. |
02/15/2019
| Implemented |
2380.70(a) | There was no first aid area separated by partition or privacy screen from the program area. | The facility shall have a first aid area that is separated by partition or privacy screen from program areas. | We will purchase a screen that will create a private area and serve as a partition between the medical area and program area.
The screen will be portable and will remain in the closet until it is the be used. |
02/15/2019
| Implemented |
2380.70(b) | There was no bed or cot, blanket, pillow or first aid kit. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | We will provide portable cot, a blanket and pillow in the facility, along with the first aide kit.
The items will be stored in the office closet until needed. |
02/15/2019
| Implemented |
2380.70(c) | The facility did not have a first aid kit. | Each floor of the facility shall have a first aid kit accessible to staff persons. | The facility will purchase a first aide kit that is accessible to all staff person.
The kit will be checked monthly to ensure all necessary items are restocked and in place. |
02/15/2019
| Implemented |
2380.70(d) | There were no first aid supplies required for a first aid kit. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | Our purchased first aide kit will include adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape and scissors.
The first aide will be checked monthly to ensure all contents are present. |
02/15/2019
| Implemented |
2380.70(e) | There was no first aid manual. | A first aid manual shall be kept with each first aid kit. | We will ensure the first aide manual is located along with the first aide kit.
We will check the kit monthly to ensure the manual is in the kit. |
02/15/2019
| Implemented |
2380.72(b) | The sidewalk leading to the front entrance of the building had a gap between two large concrete slabs, creating a potential tripping hazard. | The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions. | We will fill in the gap between the slabs in the front of the building. The work will be completed early spring
when the weather is more conducive to the setting of the concrete.
We will check for cracks and potential hazards monthly. |
05/16/2019
| Implemented |
2380.88(f) | The fire extinguishers in the facility were last inspected and approved in August 2017. | Fire extinguishers shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | We will install be at least a fire extinguisher with a minimum 2-A rating inside the facility.
Fire extinguishers will be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. |
01/15/2019
| Implemented |