| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(g) | Staff # 1's fire safety training dated 09/07/2014 was not conducted by a fire safety expert
Staff # 2's fire safety training dated 09/04/2014 was not conducted by a fire safety expert
| Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | 1. The fire safety on-line training was discontinued on 4/13/2016. Staff #1 was trained by a fire safety expert on 5/17/2016. See attachments #10 and #11. Staff #2 was trained by a fire safety expert on 5/3/2016. See attachments #12 and #11.
2. All employees who took the on-line course since 7/1/2015 to 4/13/2016 were instructed to complete the in-class fire safety conducted by a fire safety expert by 10/1/2016.
3. In order to prevent reoccurrence, Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in 55 PA Code Chapter 6400.46(g). On-line courses in this area will not be accepted. |
10/01/2016
| Implemented |
| 6400.62(c) | A white spray bottle was found with a handwritten label that read "windex". | Poisonous materials shall be stored in their original, labeled containers. | 1. The white spray bottle was removed in the presence of the inspector on 4/12/2016.
2. The Program Coordinator will complete a site inspections on all other programs by 9/30/2016 and document compliance on 55 PA Code Chapter 6400.62(c) on the Licensing Inspection Instrument Score Sheet section Physical Site. All areas of non-compliance will result removal of any poisonous materials that are not stored in their original, labeled containers and retraining of the staff and supervisor will occur.
3. In order to prevent reoccurrence, the Program Coordinator retrained the Program Supervisors on 55 PA Code Chapter 6400.62(c) on 8/11/2016. See attachment #8. The Program Supervisor will remove any poisonous materials that are not stored in their original, labeled containers 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 plan of correction and retraining. |
09/30/2016
| Implemented |
| 6400.67(a) | The wood floor located in the living room was worn and there were scratches and black marks on the floor covering approximately a five by six foot area. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. A professional contractor refinished the wood floor located in the living room on 6/30/2016. See attachment #4, and #4A.
2. The Program Coordinator will complete a site inspections on all other programs by 9/30/2016 and document compliance on 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 |
| 6400.168(d) | Staff # 1's previous medication administration training was completed on 05/15/2014 and the most recent medication administration training was completed on 05/31/2015. Staff # 1 administered medication from 05/16/2015-05/30/2015 and was not trained. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. Staff #1 received an annual practicum on 5/2/2016. See Attachment # 5.
2. The Program Director will conduct a staff training record review of all current employees administering medications by 9/30/2016. The review will consist of comparing the most recent medication administration training and the year prior to access non-compliance. Any staff currently administering medications and are not trained will be suspended from administering medications until they have received training.
3. In order to prevent reoccurrence, the Program Coordinator retrained all Practicum Observers on 55 PA Code Chapter 6400.168(d) on 4/14/2016. See Attachment #6. The HR Specialist will distribute a list monthly of all staff that will need their annual medication administration practicum completed within the next two months. See Attachment # 7. The Program Coordinator will review all annual practicums for accuracy and suspend any staff that is not trained from administering medication until a retraining has occurred. |
09/30/2016
| Implemented |