Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.82(e) | The shower located in Ind. number 3 bathroom did not contain a slip mat. | Bathtubs and showers shall have a nonslip surface or mat. | The nonslip mat was put in the bathtub on 4/4/23 and the picture is attached. |
04/04/2023
| Implemented |
6400.112(c) | There is no time listed on the drill held on 11/2/22. | 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 or smoke detector was operative. | All the fire Drills were reviewed to ensure everything is updated. The review was completed on 4/20/2023 |
04/20/2023
| Implemented |
6400.141(c)(3) | Individual number 3 last Tdap immunization was in 2010. This should be done every ten years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The DTAP Immunizations for individual #3 was completed on April 12 2023 at 10am. |
04/12/2023
| Implemented |
6400.169(a) | Med practicum for staff number 1 not completed properly. There need to be four observations. There needs to be two observations of medication administration and MAR review. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Per our discussion with the Lead inspector, there were violation from the documents reviewed. The training was completed per regulation. See the attached document. |
04/04/2023
| Implemented |