| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(b) | The hot water temperature was measured at 122.5 degrees Fahrenheit in the sink located in the Ladies bathroom.
NOTE: The building maintenance person turned down the temperature of the hot water at the time of the inspection. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The water temperature in the facility was decreased at the time of the inspection on October 19, 2023. |
10/19/2023
| Implemented |
| 2380.113(a) | Staff #1's current physical examination was completed late. Staff #1's previous physical examination was completed on 11/15/2019 and their current physical examination was completed on 1/21/2022. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Program Specialist will ensure that all staff meet the requirements for completion of physical. |
10/20/2023
| Implemented |
| 2380.113(c)(2) | Staff #1 completed Tuberculin skin testing by Mantoux method late. Staff #1's previous Tuberculin skin testing was completed on 11/15/2019, and their current Tuberculin skin testing was completed on 1/24/2022. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | Program Specialist will ensure that all staff meet the requirements for completion of physical. |
10/20/2023
| Implemented |