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 outcomes of "community" and "self-sufficient" were measured by the same strategies implemented during the previous ISP dated 10/19/2014 as well as the current ISP dated 10/19/2015 regardless of progress or lack of progress towards achieving the outcomes. | 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¿ and ¿self-sufficient¿ that will reflect different strategies that were implemented in the previous ISP dated 10/19/2015. This will be recommended in the individuals next Quarterly Review completed after 10/18/2016.
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 8/31/2016. 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. |
10/31/2016
| Implemented |