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 is licensed for 4 and one person required physicial assistance to evacuate the home on 10/3/12, 10/6/12, 11.11.12, 12/7/12, 1/16/13, 2/5/13 and 3/2/13. | (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 have identified a home with an existing C1 Certificate of Occupancy for the individual to move to. In the interim the individual will be using her walker with staff providing physical assistance as needed to ensure safe and timely evcauation. This procedure has been put in writing and staff were trained on 4/22/13. Documentation will be scanned and emailed. |
04/30/2013
| Implemented |
6400.104 | On 4/1/12, 4/18/12, and 5/2/12 the patio sliding doors were used to exit during monthly fire drills and on 6/6/12, 6/9/12, 7/18/12, and 8/3/12 the front door was used to exit the home during monthly fire drills. | 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.
| Revised letter sent 3/27/13. Director will more closely monitor fire safety and notifications to fire department. See supporting documentaion that has been scanned and emailed. |
03/27/2013
| Implemented |
6400.141(c)(15) | Special diet instructions to not lay down for 2-3 hours after eating was not included on physical examination completed 10/1/12. | (15) Special instructions for the individual's diet.
| received diet instructions on 3/27/13. Staff were trained on 3/30/13. PD will ensure better clarification from physician and staff training. |
03/30/2013
| Implemented |
6400.144 | Prescribed medical health care to complete yearly hemeoccult labwork was not completed. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| physician discontinued the need for hemeoccult on 4/8/13. pd will closely monitor medical follow-ip |
04/08/2013
| Implemented |
6400.181(f) | There was no documentation that a assessment completed 10/5/12 was sent to the Support Corrdinator 30 days prior to the meeting date for ISP held on 11/12/12. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| PD will ensure that cover letters are sent with each assessment prior 30 days to ISP meeting. Staff were trained 4/3/13. |
04/03/2013
| Implemented |
6400.186(c)(2) | ISP review completed 4/6/12 did not include a complete review of the ISP. | (2) A review of each section of the ISP specific to the residential home licensed under this chapter.
| The ISP review which was sited was completed on 4/6/12 prior to the form being updated to include all areas of the ISP. PD will ensure the new format is used. Staff trained 4/3/13 |
04/03/2013
| Implemented |