| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.62 | The telephone in the program area did not have a list of emergency telephone numbers posted on or nearby it. | 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. The Vice President/Chief Operating Officer will monitor the telephone list to ensure it is in place on a monthly basis. | An emergency contact list including the numbers for fire dept., police, ambulance all local hospitals and the poison control center has been posted as required. |
01/23/2015
| Implemented |
| 2380.86 | There was a space heater near the receptionist at the front door of the program. The CEO stated that the area becomes very cold if the receptionist is not permitted to use it. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices. | The HVAC system in our building is over 40 years old. On occasion, it fail to provide adequate heat for the lobby. We will contact our HVAC vendor to determine if the existing system can be improved. If not, we will have another type of heating unit permanently mounted in the lobby by 4/30/2015. The Vice President/Chief Operating Officer will monitor for portable space heaters on a monthly basis. |
01/20/2015
| Implemented |
| 2380.88(a) | The stage has a fire extinguisher that is not charged. | There shall be at least one fire extinguisher with a minimum 2-A rating for each floor including the basement. | Our Fire Extinguishers are inspected annually. This particular unit had a valid inspection date but the charge level had dropped below an acceptable. Our vendor was contacted and the unit in question was re-charged on the same day as the inspection. The Maintenance person will monitor all fire extinguishers to ensure they are in compliance on a quarterly basis. |
12/23/2014
| Implemented |
| 2380.113(a) | The program specialist had a physical on 10/31/2012. However, there was no other physical presented for this program specialist (staff #1). | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Goodwill Industries requires that all employees get a pre-employment physical prior to their start date. Additionally, we maintain a listing of all Adult Training Facility employees and their date of hire. As they approach their second anniversary, each individual is notified that another physical examination is required. These records are reviewed quarterly as part of our Quality Management System with the Vice President/COO overseeing. Staff #1 received her physical on 12/29/2014. |
01/20/2015
| Implemented |
| 2380.113(c)(2) | The program specialist had a TB test conducted on 6/11/10 and 10/31/2012. However there is no documentation showing the results of either TB test. There is no TB test for this program specialist for 2014. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | After a thorough investigation, it appears that this was an isolated incident. In order to minimize this from occurring in the future, we will review an individuals pre employment physical records prior to their start date. We will also remind appropriate staff that an physical examination including tuberculin testing is required every two years. This review process will also become part of our Quality Management System with oversight by the Vice President/COO. Staff #1 received her TB test on 12/29/2014, which was read as negative on 12/31/2014. |
01/20/2015
| Implemented |