Observations
During the physical plant inspection on March 17, 2022, the facility failed to ensure that the facility was safe and in good repair. The 2nd floor woman ' s/children ' s lounge area had exposed coils of a heater located by the kids play area and in one client's bedroom there was an exposed metal frame which is utilized by one of the children.
Findings were addressed with facility staff during the compliant investigation.
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Plan of Correction
The deficiency was corrected on 3/17/2022.
The correction will be maintained by taking the following action steps:
1. The Facility Director will disseminate the Building and Grounds Policy and Procedures and review procedures with operations department personnel, to include identification and reporting of areas in need of maintenance and repair, as well as furnishings in need of repair or removal.
The corrective action will be maintained by the following:
1. Whenever it comes to the attention of any staff member that any hazardous or poor conditions exist, or furnishings are in disrepair, a work order is to be entered into the facilities management system for timely attention by maintenance personnel.
2. All furnishings in clients' living areas will be inspected monthly by maintenance personnel who are to ensure that all furnishings are in good working order and identify any furnishings that need removal, repair or replacement.
2. The Director of Operations or the Facility Director shall review with maintenance personnel all furniture inventory reports and develop an interim plan for use, when necessary and a timeline for the repair or replacement of identified furniture.
3. The management team of the facility will develop and implement written standard work procedures for maintenance services that are organized to include all areas for improvement that have been identified by this inspection. |