| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1, admission date 5/21/18, initially signed the statement acknowledging receipt of the information on individual rights on 5/24/18. | 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. | 1. Mandatory meeting for all management staff educating all clinical managers that the Individual Handbook which contains all individuals rights will be given to individual on day of admission. 55PA Code Chapter 6400.31(b).
2. All new admissions will have Individual Handbook completed and signed on day of admission. Copies to be sent to CEO on day of admission.
Responsibility: Deborah L. Price, CEO; All Residential Directors; All Residential Supervisors;
Correction Date: 09/21/2018 and repeated on 10/23/2018. |
09/21/2018
| Implemented |
| 6400.101 | The door leading to the attic of the home was equipped with a padlock locking system preventing egress from the attic when engaged. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1. Padlock removed and replaced with a breakaway door knob. Opens without a key from exit side of door.
2. All homes checked for locks preventing egress, none found. 55 PA Code Chapter 6400.101
Responsibility: Deborah L. Price, CEO; Fred Raszmann, Maintenance Worker |
09/21/2018
| Implemented |
| 6400.113(a) | Individual #1, admission date 5/21/18, had initial fire safety training on 5/25/18. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 1. Mandatory meetings for all management staff educating all clinical managers that fire training will be done on first day of admission, 55 PA Code Chapter 6400.113(a).
2. All new admissions will have fire training completed and copies sent to CEO on day of admission.
Responsibility: Deborah L. Price, CEO; All Residential Directors; All Residential Supervisors;
Correction Date: 9/21/2018 and repeated on 10/23/2018. |
09/21/2018
| Implemented |