| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was a missing ceiling tile and a broken ceiling tile in the basement. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The maintenance department replaced all missing and broken ceiling tiles on 4/25/2016. See attachment #3.
2. The Program Coordinator will complete site inspections on all other programs by 9/30/2016 and document compliance with 55 PA Code Chapter 6400.67(a) on the Licensing Inspection Instrument Score Sheet section Physical Site. All areas of non-compliance will result in a maintenance request to be fixed.
3. In order to prevent reoccurrence, the Program Coordinator retrained the Program Supervisors on 55 PA Code Chapter 6400.67(a) on 8/11/2016. See attachment # 8. The Program Supervisor will submit a maintenance request whenever physical site non-compliance is recognized. The Program Coordinator/Property Manager will conduct site inspections for each licensed program once a quarter and document the results using the Licensing Inspection Instrument Score Sheet section Physical Site. All areas of non-compliance will result in a maintenance request to be fixed. |
09/30/2016
| Implemented |
| 6400.112(a) | Through staff interviews, it was determined fire drills are not always unannounced. | An unannounced fire drill shall be held at least once a month. | 1. Previous non-compliant practices of conducting an unannounced fire drill each month cannot be corrected.
2. In order to prevent reoccurrence, the Program Coordinator retrained all Program Supervisors (responsible for conducting all fire drills) on 4/14/2016 on 55 PA Code Chapter 6400.112(a) ¿was an unannounced fire drill held at least once a month.¿ See Attachment # 2.
3. The Program Coordinator will interview each staff present during a fire drill at each program by 9/30/2016 to track compliance. This will be documented on Attachment #1. |
09/30/2016
| Implemented |
| 6400.186(c)(4)(iii) | Individual # 1's outcome of "community outings" was measured by the same strategies implemented during the previous ISP dated 09/11/2014 as well as the current ISP dated 09/11/2015 regardless of progress or lack of progress towards achieving the outcome. | The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. | 1. The Program Specialist will recommend modification to individual # 1¿s outcome of ¿community outings¿ that will reflect different strategies that were implemented in the previous ISP dated 9/11/2015. This will be recommended in the individuals next Quarterly Review completed after 9/10/2016.
2. The program specialist will review all individuals¿ current and previous ISPs outcomes in the program by 9/30/2016. Recommendations will be made on the next quarterly review if strategies implemented from the current and previous ISP were duplicated.
3. In order to prevent reoccurrence, the Program Specialist Supervisor will retrained all Program Specialist on how to properly implement 55 PA Code Chapter 6400.186(c) (4)(iii) by 4/25/2016. See attachment #17. The Program Specialist will conduct a quarterly audit using the Licensing Inspection Instrument Score Sheet section Plan Review and Plan Revision to track future compliance. The Program Specialist Supervisor will track and monitor the audit results. |
09/26/2016
| Implemented |