| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is no working light in basement. There were two empty light receptacles with no bulbs. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Ticket to replace bulbs was submitted with Bancroft's facilities department on 2/08/2022. Maintenance replaced the missing light bulbs in the basement on 2/9/22. |
02/09/2022
| Implemented |
| 6400.67(a) | The basement walls need to be resurfaced/repaired. There is a black substance forming on the basement walls. | Floors, walls, ceilings and other surfaces shall be in good repair. | Ticket was submitted with Bancroft's facilities department on 2/08/2022, currently waiting on the work to be completed. The senior program associate and/or program director will continue to follow up with the facilities team. |
03/31/2022
| Implemented |
| 6400.67(b) | There was lint found in filter of dryer which presents a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Program Manager removed the lint during the inspection on 12/15/2021 |
02/11/2022
| Implemented |
| 6400.67(b) | There are several large hanging wires in basement. There is paint chipping from exposed beams in the basements. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Ticket was submitted to our facilities department on 2/08/2022, currently waiting on the work to be completed |
03/31/2022
| Implemented |
| 6400.101 | There is a large tool on bottom stair of basement which can cause an obstruction when using the stairs to go up and down. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The item at the bottom of the stairs was left by a contractor after a repair was completed in the basement. Ticket was submitted to Bancroft's facilities department to remove the item. Maintenance team removed the item on 2/9/22. The stairway is now clear. |
02/09/2022
| Implemented |
| 6400.110(a) | The smoke detector in the basement was inoperable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Ticket submitted 2/08/2022 to Bancroft's facilities department who has contacted our alarm contractor, Independent Alarm. Facilities is currently awaiting a response from Independent Alarm System regarding the basement smoke detector. The smoke detector in the basement is operable. |
03/31/2022
| Implemented |
| 6400.110(e) | Smoke detectors were not interconnected and the home is three levels. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Ticket submitted 2/08/2022 to Bancroft's facilities department. Facilities is currently awaiting a response from Independent Alarm System regarding the basement smoke detector. |
03/31/2022
| Implemented |
| 6400.46(b) | It could not be determined if staff member #2 completed annual fire safety training-last record was 10/13/17-no other fire safety training provided for this staff member-requested but not provided by agency. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff training records were obtained from program records, Bancroft's Organizational Development and Learning Department and Healthstream. |
02/14/2022
| Implemented |
| 6400.46(d) | It could not be determined if staff member #2 completed annual CPR/first aid training as last record was 10/13/17- requested but not provided by agency. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff training records were obtained from program records, Bancroft's Organizational Development and Learning Department and Healthstream. |
02/14/2022
| Implemented |
| 6400.52(a)(1) | It could not be determined if staff member #2 completed 24 hours of annual training as required-training year ending 2020 was requested but not provided at inspection | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff training records were obtained from program records, Bancroft's Organizational Development and Learning Department and Healthstream. |
02/14/2022
| Implemented |
| 6400.52(a)(1) | It could be determined if staff member #3 completed 24 hours of annual training as the current training record was not available at inspection. 2019 training record was provided. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Agency was unable to provide a 2020 training record due to an outage in the Kronos system where 2020 and past training records are stored. Training records for 2021 and ongoing are now kept in the Healthstream system. Training record was retrieved from Kronos system. |
02/14/2022
| Implemented |