| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | Fire drills conducted on 9/6/22, 8/25/22, 6/18/22, 5/27/22, 4/24/22, 1/31/22, 11/29/21, 10/22/21, 9/15/21 and 8/11/21 all exceeded the allowed evacuation time of 2 ½ minutes. There was no documentation of an extended evacuation time in place to cover the timeframe of the related drills. A letter from the Department Chief of the Hanover Area Fire District dated 9/6/22 stated that "It is deemed acceptable that 4 minutes for the residents would be acceptable if they were asleep as was the past time line for evacuation." The 9/6/22 letter in place at the time of inspection does not fully satisfy compliance standards. Items missing from the 9/6/22 letter are whether individuals should evacuate outside of the home or to a fire-safe area, a statement attesting that the extended time (and fire-safe area is based on the design and construction of the home and not on the needs of the individuals served, and an attestation that the fire safety expert meets the qualifications as specified in Chapter 6400. The 9/6/22 letter is not compliant and therefore the evacuation time given of 4 minutes is not valid. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Program Manager will contact fire safety expert to clarify if an extended evacuation time is necessary and meets safety needs. Program Specialist will also contact a fire safety expert to provide training to all individuals in the home regarding fire safety. |
11/22/2022
| Implemented |
| 6400.52(c)(2) | There was no documentation to support that Staff #5 had annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101--- as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | DSP will be required to complete training immediately. Failure to complete training by 10/31/22 will result in suspension. |
10/31/2022
| Implemented |
| 6400.169(a) | Documentation illustrates that Staff #5 last received medication administration training on 5/4/21. There was no documentation to support that course renewal requirements had been satisfied per regulation. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The staff member identified in the review is currently being retrained under the new department approved medication administration training. Training is scheduled to be completed by the end of November 2022. |
12/09/2022
| Implemented |