| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(b) | At the time of the 05/29/25 Inspection, there were three water faucets that registered hot water temperatures above 124 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | On 6/3/2025, the C-NTA Maintenance Manager identified the need to install a mixing valve to ensure hot water temperatures remain below the regulatory limit of 120 degrees Fahrenheit. A new water heater and mixing valve were installed on that same date. Following installation, the water temperature at the fixture closest to the water heater was set and verified at 119.4 degrees Fahrenheit using a calibrated waterproof stem thermometer.
To verify the system is functioning properly, the maintenance team will perform weekly water temperature checks at multiple fixtures through 6/30/2025. All temperature readings will be documented and reviewed to confirm compliance. |
06/03/2025
| Implemented |
| 2380.61 | At the time of the 05/29/25 Inspection, the only telephone in the facility was located in an office that also functions as the Private First Aid Area. | The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. | C-NTA has identified the need for a phone to be readily accessible to both individuals and staff on the program floor. To address this, the landline phone that was located in the First Aid Room was relocated by the Program Director to a central location on the program floor on 5/29/2025, ensuring immediate access for communication during program hours. To maintain functionality and ensure privacy for health-related or sensitive conversations, a second landline will be installed in the First Aid Room by 6/13/2025. This placement will allow staff to make confidential calls related to health, emergency response, or personal matters in a private and appropriate setting. |
05/29/2025
| Implemented |
| 2380.62 | At the time of the 05/29/25 Inspection, Emergency Phone Numbers were not posted on or near the telephone. | 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. | C-NTA identified that emergency phone numbers were not posted at the program floor phone, as required. To immediately correct this, a printed emergency contact list including 911 (police, fire, ambulance), Poison Control, the nearest local hospital, and internal emergency contacts was posted by Program Director next to the relocated landline on the program floor as of 5/29/2025.
As referenced in a related Plan of Correction, a second landline will be installed in the First Aid Room by 6/13/2025. Upon installation, the same emergency contact list will be visibly posted near the new phone to ensure accessibility to essential emergency information in both critical locations. |
05/29/2025
| Implemented |