| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | Access to the electric closet was not made accessible to the staff/individuals and/or licensing during inspection. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | The electrical rooms are locked in all the apartment buildings. We have no access to this room. Upon inspection we will contact the management office and ask that maintenance be onsite to give access to the inspection team. |
07/07/2023
| Implemented |
| 6400.112(c) | The drill from 9/8/22 does not indicate whether smoke detectors were used or operational during the drill. Individuals were verbally prompted to leave during the drill. | 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. | The fire drill forms have been updated to ask the question of the smoke detector being operable. The lead staff have been trained on the importance of the smoke detector being operable and that yelling fire-fire is not enough. |
07/12/2023
| Implemented |
| 6400.141(c)(1) | Individual's 7/29/22 p#1hysical indicates their medical history was not reviewed. | The physical examination shall include: A review of previous medical history. | The physical form was updated to move this question (was the LTM reviewed) to different section of the form. The Lead staff have been informed of the importance of the doctor answering this question correctly. The Lead staff will review the completed form before leaving the PCP's office to ensure accuracy of this question. |
07/10/2023
| Implemented |
| 6400.141(c)(3) | Individual#1 has not had a flu shot since November 2020. Their 7/29/22 physical also indicates that there is no record showing a current shingles vaccine. The physical indicates one was ordered in 2020 but its completion was not verified. | 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. | We have a new Policy and Procedure that requires all individuals receive a flu shot in the months of September and October when they are first released. The immunization section of the physical has been updated to include a section to list other vaccines/immunizations the doctor recommends. |
09/15/2023
| Implemented |
| 6400.141(c)(10) | Individual#1's 7/29/22 physical does not indicate their communicable disease status. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | When the TB happens separate from the annual physical a copy of the TB results will be kept with the physical from. The PCP will be asked to include the results on the annual physical form. |
06/05/2023
| Implemented |