| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | Cleaning supplies which indicated to contact poison control if ingested were found stored with corn flakes, V-8 splash, and fruit loops in a cabinet under the sink | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | 1. The cleaning supplies were removed in the presence of the inspector on 4/12/2016.
2. The Program Coordinator will complete site inspections on all other programs by 9/30/2016 and document compliance on 55 PA Code Chapter 6400.62(d) 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 separate from food, food preparation surfaces and dining surfaces 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(d) on 8/11/2016. See attachment #8. The Program Supervisor will remove any poisonous materials that are not stored separate from food, food preparation surfaces and dining surfaces 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 |
| 6400.64(a) | Individual # 1's bedroom and the adjoining bathroom had a strong smell on urine | Clean and sanitary conditions shall be maintained in the home. | 1. Individual #1¿s bedroom and adjoining bathroom were cleaned with ¿Clorox Urine Remover. ¿
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 6400.64(a) on the Licensing Inspection Instrument Score Sheet section Physical Site. All areas of non-compliance will result cleaning and sanitizing the area 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 6400.64(a) on 8/11/2016. See attachment #8. The Program Supervisor will facilitate cleaning of any unsanitary physical site non-compliance when 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 |
| 6400.112(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 |