Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.53(c) | Food items were stored in a locked closet along with cleaners. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | CEO will educate all staff that no foods are to be stored in any area that contains poisonous materials. All foods are to be removed immediately from locked storage cabinet containing cleaners and placed in the kitchen in cabinets. |
02/20/2023
| Implemented |
2380.82 | A non-fire exit leading to the breezeway did not have a latch on the interior lock. Both sides of the lock were key enabled. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | Lock was replaced on 2/16/2023 . Photo sent to licensing. |
02/16/2023
| Implemented |
2380.89(a) | A fire drill was not completed for November 2022. | An unannounced fire drill shall be held at least once a month. | We had realized that we had not performed the fire drill for November 2022 on December 7, 2022. We immediately conducted an unannounced fire drill that day, Dec. 7, 2022. |
02/10/2023
| Implemented |
2380.91(a) | There is no fire safety training for Individual #2 or Individual #3. | An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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, and smoking safety procedures if individuals smoke at the facility. | Individuals #2 and #3 were instructed in English on February 1, 2023 about fire safety, were escorted through evacuation procedures on that day, instructed in fire drill responsibilities, shown in person the designated outside meeting safe place in the event of an actual fire (same area as fire drill safe space), and instructed in smoking safety procedures, which is at least 30 feet away from the building. A signed training record was emailed to Licensing. |
02/01/2023
| Implemented |
2380.111(c)(10) | Information pertinent to diagnosis and treatment in case of emergency is blank on the physicals for Individual #2 and Individual #3. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The RN/CEO will contact both individual #2 and #3 and guardians, ask them to contact physician/PCP and add medical information pertinent to diagnosis and treatment in case of emergency. |
02/27/2023
| Implemented |
2380.39(c)(6) | Verification that the annual plan implementation training was completed was not documented in the files for Staff #1 & Staff #2. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #1 and Staff #1 completed the Foundations of ISP Development ODP module. Photos of training evidence sent to Licensing. |
02/27/2023
| Implemented |
2380.123(d) | The medication Clonazepam 2mg tablet prescribed to Individual #1 was stored in an unlocked bag in the program space. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | CEO will purchase locked containers for all prescription medications and syringes.
The Clonazepam 2 mg. was placed in a locked container. A photograph of this medication and locked container will be sent to Inspector. |
02/17/2023
| Implemented |