Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.14(a) | The home does not have a valid fire safety occupancy permit. The home has a licensed capacity of 6 and one person required physical assistance to evacuate the home on 3/20/12, 6/13/12, 8/8/12, 9/8/12, 10/17/12, 11/28/12, 12/27/12, 1/25/13, 2/22/13 and 3/19/13. | (a) If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the
appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh,
the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: Records | we were able to locate and obtain copies of C1 Certificate of Occupancy issued 9/6/1994. Scanned documents will be forwarded via email. |
04/30/2013
| Implemented |
6400.104 | Written notification letter to the fire department dated 1/28/13 does not identify that Individual #1 requires physicial assistance to evacuate the home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Letter sent to local fire department 3/27/13. Director will ensure that notifications remain current. |
04/22/2013
| Implemented |
6400.141(c)(9) | Individual #1 had a prostate examination on 2/13/12 and his next scheduled appointment was not completed until 3/21/13. | (9) A prostate examination for men 40 years of age or older.
| medical appointment will be completed on a timely basis. Medical tracking is monitored utilizing Evolv and part of agency Balanced Score Card (QMP). PD will meet with medical records supervisor on a monthly basis. |
04/22/2013
| Implemented |
6400.141(c)(12) | Individual #1 requires physical assistance to evacuate the home during a fire drill. There were no physical limitations included on physicial examination completed 6/14/12. | (12) Physical limitations of the individual.
| Phyisical limitations added to the current physical and signed off by Dr. on 4/18/2013 |
04/18/2013
| Implemented |
6400.142(e) | Individual #1 was seen by a dentist on 4/10/12. He was required to complete a follow-up appointment within six months. The follow-up appointment was completed on 2/26/13. | (e) Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | medical appointment will be completed on a timely basis. Medical tracking is monitored utilizing Evolv and part of agency Balanced Score Card (QMP). PD will meet with medical records supervisor on a monthly basis. |
04/22/2013
| Implemented |
6400.186(c)(3) | Individual #1 monthly ISP reviews for 10/12 thru 2/13 showed no progress was noted and modification to revise outcome was not recommendated to the Support Corrdinator. | (3) The program specialist shall document a change in the individual's needs, if applicable. | team meeting scheduled for 4/24/13 to discuss his change in needs and deteremine if updates need to be made to assessment and or ISP. PD will ensure that changes in needs are reflected in assessements and communicated to Supports Coordinator in a tiemly fashion. |
04/24/2013
| Implemented |
6400.188(c) | There was no programs, strategies or procedures to implement or track ISP outcomes for individual #1 outcomes which started 10/22/12. | (c) The residential home shall provide services to the individual as specified in the individual's ISP.
| Outcomes were updated and new criteria was impletmented 4/3/2013. Will review with Supports Coordinator at team meeting on 4/24/13 |
04/03/2013
| Implemented |
6400.192 | The agency Restrictive Procedure policy did not include a process for the individual or the individuals family to review the use of the restrictive procedure. | A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home.
| revision completed 3/28/13 adding that the individual and family will be informed. |
03/28/2013
| Implemented |