| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | The "Rights" forms, signed by Individual #1 on 7/25/14, and Individual #2 on 11/24/14, did not state the full rights per regulation 33(e) regarding privacy and regulation 33(j) regarding voting.
Per 6400.33(e), "An individual has the right to privacy in bedrooms, bathrooms and during personal care." Individual #1 and Individual #2's signed statements include "Each individual will be given privacy during treatment and care of personal needs."
Per 6400.33(j), "An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections." Individual #1 and Individual #2's signed statement does not include this statement. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Quality Assurance Director revised the Client Rights to include "each individual has the right to privacy in bedrooms, bathrooms, and during personal care" and "each individual who is of voting age has the right to vote and will be assisted to register and vote in the elections." The Program Specialist will have client #1 and #2 and/or parent/guardian sign the revised rights by January 6, 2015. The Administrative Assistant will send the revised Client Rights to all clients and/or parent guardian by January 15, 2015. The Program Specialist will ensure the Client Rights are reviewed and the Acknowledgement Form signed by the client and/or parent/guardian annually and filed in the client's Program Book. |
12/29/2014
| Implemented |
| 6400.103 | The written emergency evacuation procedures do not include the means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Quality Assurance Director revised the Emergency Evacuation Plan on 12/24/14 to include that the means of transportation will be by Agency and Staff vehicles and that the emergency shelter location are the Avalon Hotel on 16 West 10th Street, Erie, PA 16501, client family member's, or staff member's homes. The revised Emergency Evacuation Plan will be distributed to all group homes by january 1, 2015. |
12/29/2014
| Implemented |
| 6400.106 | The furnace has not been inspected and cleaned for several years by a professional furnace cleaning company or trained staff person. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Maintenance Manager will schedule the furnace cleaning and inspection with a professional cleaning company by January 16, 2015. The Maintenance Manager will schedule the cleaning and inspections to be done by a professional cleaning company annually. The Program Specialist will receive a copy of the cleaning and inspection reports to ensure they were done by the professionally cleaning company annually. |
12/29/2014
| Implemented |
| 6400.216(a) | Individual #1 and #2's medical record including labwork sheets were unlocked on the bulletin board in the garage. | An individual's records shall be kept locked when unattended. | The Program Specialist removed the posted Lab work for Client's #1 and #2 on 12/2/2014. The Program Specialist and Nurse Manager will reminded all the nurses and staff members that all client records must be locked at all times. The Program Specialist will conduct Confidentiality Training for the staff members on January 15, 2015. The Program Specialists of each facility will check throughout each shift she/he works to ensure client records are locked and remain confidential effective January 1, 2015. |
12/29/2014
| Implemented |