| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The written emergency evacuation procedures do not inclued 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 |
| 6400.112(c) | The fire drill record for the fire drill conducted on 7/26/14 does not include the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The Fire Drill Form had an identified space to document the exit route, but staff failed to document the exit route on the form for the 7/26/2014 fire drill. The Fire Drill Report Form Does not need to be revised to include "exit route". The Program Specialist retrained the staff members who conduct the fire Drills on how to complete the Fire Drill Report Form accurately and thoroughly on 12/22/14. All Program Specialists will review all completed Fire Drill Report Forms in their assigned houses to ensure they are completed thoroughly and accurately. The Senior Community Home Coordinator will conduct random reviews of the Fire Drill Report forms to ensure they are completed accurately and thoroughly. |
12/29/2014
| Implemented |