| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(b) | The hot water temperature exceeded the 120*F in the kitchen measured at 132.8*F, in the bathrooms 132.1*F and in the nurse, office measured at 131.2*F. (Agency corrected the water temp) | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | On Thursday 2/17/2022 Center Director and Program Assistant decreased the temperature on the facility's hot water heater. |
05/16/2022
| Implemented |
| 2380.88(f) | The Fire Extinguisher located in the supply room was last inspected in May 2009. | Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher in question was located in an area listed "Not in Scope", as listed on our facility's blueprint. Apparently the fire extinguisher was here prior to this agency as we¿ve ONLY been in this space for close to 7 years as documented on our Certificate of Occupancy. The facility has the correct amount of
fire extinguishers for this space (three; all of which are compliant). See Attachments 2 and 3. |
05/16/2022
| Implemented |
| 2380.89(d) | Fire drills dated 5/21, 7/21, 8/21, 9/21, 10/21, 11/21, and 12/21 all exceeded the 2 ½ minutes, agency did not provide in writing by a fire safety expert extending the evacuation period. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility. | Center Director and staff will now utilize devices (wheelchairs, and seated rollators) to assist individuals during fire drills to meet state compliance of timely evacuations. |
05/16/2022
| Implemented |
| 2380.111(a) | Individual #1 file does not contain a record of an annual physical from the past year. The most recent physical in their file is dated 1/28/21. During the inspection, the facility provided an email showing that a physical has been scheduled for 2/21/22. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Each Member will have a record of an annual physical examination within 12 months prior to admission, and annually thereafter. |
05/16/2022
| Implemented |
| 2380.111(c)(10) | Individual #2, 3/18/21 physical does not contain information pertinent to diagnosis and treatment in case of emergency; that portion of the physical was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Every Member's examination will include: Medical information pertinent to diagnosis and treatment in case of emergency |
05/16/2022
| Implemented |
| 2380.173(1)(ii) | It cannot be determined that Individual #2 file contains a record of their race. The identifying marks section was also left blank on their face sheet. During the inspection, the facility updated the individual's information sheet to include a record of identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The facility will ensure that personal information; including race, height, weight, color of hair, color of eyes and identifying marks are documented in each Member's chart. |
05/16/2022
| Implemented |
| 2380.173(1)(ii) | It cannot be determined that Individual #1 file contains a record of their race. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The facility will ensure that personal information; including race, height, weight, color of hair, color of eyes and identifying marks are documented in each Member's chart. |
05/16/2022
| Implemented |
| 2380.181(c) | Individual #1 6/23/21 assessment does not list the sources of its information. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The facility will ensure that all Member assessments are documented to show the assessments are based on interviews, progress notes, and observations. |
05/16/2022
| Implemented |
| 2380.154(a) | The facility does not have a Human Rights Team to oversee and respond to issues related to the usage or implementation of restrictive procedures for the individuals it serves. | If a restrictive procedure is used, the facility shall use a human rights team. The facility may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | On 2/18/2022 Center Director met with Activities Coordinator and Program Specialist to review the Office of Developmental Programs Bulletin Number 00-18-0X; Guidance for the Development of Human Rights Teams and Human Rights Committees. On 3/24/2022 the facility developed and implemented a Human Rights Team to oversee and respond to issues related to the usage or implementation of restrictive procedures for our Members. This Committee will be facilitated by the Program Specialist. |
05/16/2022
| Implemented |