| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no lighting located outside the basement exit, the bulb was blown out. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Light bulb has been replaced. |
12/31/2021
| Implemented |
| 6400.67(b) | Lint build-up the size of a tennis ball was located in the dryer at time of inspection, which could cause a fire hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Lint was removed immediately. Staff have been educated and reminded to empty lint tray after every use of the dryer. |
12/31/2021
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain: Thermometer, antiseptic and tape. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Thermometers were removed from first aid kits to complete covid temperature screenings for employee and visitors. A separate thermometer was purchased for the first aid kit. First aid tape and antiseptic was also purchased. A section of Bancroft's monthly health and safety checklist the items that the first aid kit shall contain. |
02/11/2022
| Implemented |
| 6400.112(a) | A fire drill was not completed in 9/2021 for 2777 Highland Ave. | An unannounced fire drill shall be held at least once a month. | August was a new admission. We do not have a September drill documented. Drills were run in September with this individual; however, they were unsuccessful. Going forward, the staff team will document attempted drills. If a drill is unsuccessful, the program manager and program director will be notified, and the drill will be run again. |
02/10/2022
| Implemented |
| 6400.112(e) | No sleep drills took place at this residence over the course of 6 months. | A fire drill shall be held during sleeping hours at least every 6 months. | Program leadership reviewed this finding with the program manager team. In turn the program manager reviewed fire drill documentation with their staff team. Regulation 6400.112(e) was reviewed with the staff team. |
02/11/2022
| Implemented |