| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.101 | The doorway from the old kitchen area into the sunroom/storage room was blocked by large galvanized drink tub and chair. The door included a curtain over the glass, but still resembled a door. The egress door leading from the sunroom/storage room to the outside of the home is blocked by a chair sitting outside the home. The agency reported, they do not use these doors leading to the outside of the home as an egress route. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | The doorway from the old kitchen area into the sunroom/storage room was blocked by large galvanized drink tub and chair. The door included a curtain over the glass, but still resembled a door. The egress door leading from the sunroom/storage room to the outside of the home is blocked by a chair sitting outside the home. The agency reported, they do not use these doors leading to the outside of the home as an egress route.
The door in question is currently not a designated egress in the home. This door is never used as an exit by anybody and does have the appearance of being an exit. There is a curtain at the door and a chair placed in front. At this time there are 3 other exits available (attachment #7,8,9) & they are designated as such in the fire safety plan. (Attachment # 10)
The door has been made accessible from the inside, through the sunporch to the outside. The sunroom is currently being used as a storage area for the daughter¿s belongings, however there is a path through the room that allows an exit route if necessary. The family future plans are to convert this area into the main entrance into the home.
All designated egresses in the fire safety plan will continue to be accessible in Life Sharing Homes according to regulation 6500.101. Current Fire Safety Plan was updated to include this exit. (Attachment #13) This regulation will be monitored on a monthly basis as part of the home safety check. (Attachment# 12) Corrected 12/31/19 |
12/31/2019
| Implemented |
| 6500.109(d) | All smoke detectors were not checked for operability during or shortly after the fire drill held on 6/29/19. The fire drill log states that the smoke detector used during the drill, the laundry room detector, was the only detector operable. The monthly smoke detector checks stated that smoke detectors were checked on 6/17/19, which is not the day of the fire drill or shortly after. This is the same for the fire drill held on 1/1/19; fire drill log states upstairs hall smoke alarm was used and operable while monthly smoke detector check log wasn't completed for all smoke detectors until 1/14/19. All smoke detectors were also not checked for operability during or shortly after the 9/1/18 fire drill.
Family member #2, who is completing the quarterly fire drills for the home, has not actually timed the fire drills to know the exact time of evacuation. According to her fire drill log, every fire drill completed on a quarterly basis from 9/1/15-9/1/19 has taken "2 minutes" for evacuation. The time is never varied. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the smoke detector was operative. | Why is the regulation important? This regulation is important so that fire drills are recorded properly and practiced according to the specific regulations. Adherence to this regulation helps to better prepare the individuals how to response in the case of an actual fire.
What happened? Family member #2, who is completing the quarterly fire drills for the home, has not actually timed the fire drills to know the exact time of evacuation. According to her fire drill log, every fire drill completed on a quarterly basis from 9/1/15-9/1/19 has taken "2 minutes" for evacuation. The time is never varied.
Why did it happen? The life sharing provider conducted a fire drill on 9/1/19 and failed to record the exact time of evacuation using minutes and seconds. LS provider rounded the start time and the finish time by using her watch. She stated that it took 2 minutes.
What do we do right now? A fire drill was conducted on 11/22/19 as part of the fire safety training with all family members. Life Sharing provider used a stop watch to time the drill and will do so in the future, recording the exact time of evacuation in minutes & seconds.
How do we prevent this from happening again? All future fire drills will be timed with a stop watch and recorded to the seconds. A drill was conducted on 11/29/19 using this method. Life Sharing provider was retrained on this regulation on 10/29/19 (attachment #4) Corrected 11/29/19 (Attachment#6) |
11/29/2019
| Implemented |
| 6500.110(c) | Family member #1 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection and have been living there for more than 31 calendar days. Fire safety training to include general fire safety, evacuation procedures, designated meeting place, responsibilities during the fire drill, the use of smoke detectors and fire extinguishers, smoking safety procedures and notification of the fire department was never completed for any of the three family members. | Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a). | It is important that all persons residing within the home participate in fire safety training so that in the event of a fire they would be better prepared as to how to respond. This is very important for the safety of all residents.
Family member #1 and her two children have moved back into the residence since the last year's inspection and have been living there for more than 31 calendar days. Fire safety training to include general fire safety, evacuation procedures, designated meeting place, responsibilities during the fire drill, the use of smoke detectors and fire extinguishers, smoking safety procedures and notification of the fire department was never completed for any of the three family members.
This was an oversight of the Life Sharing Specialist to ensure that all family members are trained within 31 calendar days of moving back into the home. The adult daughter and children unexpectedly moved back into the family home with her two children and fire safety training was not completed within the time line per regulations.
Fire safety training was completed with Family member #1 and her two children on 11/22/19. All individuals residing in the home participated in this fire training along with Family Member #1 and 2 children.(Attachment#5)
Life sharing provider was retrained on Reg. 110(c) on 10/29/19. Life Sharing Specialist will ensure that all family members do have initial and annual fire safety training. Life Sharing provider will document fire safety training on annual training log that is checked by the LS Specialist. Corrected 11/22/19 (attachment#4) |
11/22/2019
| Implemented |
| 6500.125(a) | Family member #1 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection. A physical examination was never completed for any of the three family members. There is no evidence that the family member's physician has deferred to exam any of the three family members. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | Why is the regulation important? This regulation is important for all individual¿s that reside in the home. This helps to ensure good health for all family members and that there are no health concerns that could put another family member at risk.
What happened? Family member #1 and her two children, have moved back into the residence since the last year's inspection. A physical examination was never completed for any of the three family members.
Why did it happen? This was an oversight of the Life Sharing Specialist to secure a new physical on family member #1 and her two children. The adult daughter and children unexpectedly moved back into the family home with her two children without a current physical on file.
What do we do right now? Physicals were obtained for family member #1 as well as the 2 children. (attachments#2,3 & 4)
How do we prevent this from happening again? Prior to someone moving into the licensed Life Sharing home, a physical will be completed on that person. Life Sharing Provider will inform LS Specialist of any such changes. LS Provider was re-trained on this regulation on 10/29/19. (Attachment#4) Corrected: 12/11/19 |
12/11/2019
| Implemented |
| 6500.125(c)(2) | Family member #2 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection. A Tuberculin skin test with negative results was never completed for any of the three family members. There is no evidence that the family member's physicians have deferred the Tuberculin skin test for any of the three family members. | The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. | Why is the regulation important? This regulation is important in order to prevent the spread of TB within the home that is occupied by a life sharing resident.
What happened? Family member #1 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection. A Tuberculin skin test with negative results was never completed for any of the three family members. There is no evidence that the family member's physicians have deferred the Tuberculin skin test for any of the three family members.
Why did it happen? This was an oversight of the Life Sharing Specialist to secure a new physical on family member #1 and her two children. The adult daughter and children unexpectedly moved back into the family home with her two children without a current physical.
What do we do right now? Physicals were obtained for family member #1 and the two children. Family member #1 had a TB Mantoux test completed and read with negative results, the Doctor. The Doctor signed off the children's physicals that a TB test was n/a. (Attachment#1,2&3)
How do we prevent this from happening again? Prior to someone moving into the licensed Life Sharing home, a physical will be completed on that person. Life Sharing Provider will inform LS Specialist of any such changes. LS Provider was re-trained on this regulation on 10/29/19. (Attachment#4) Corrected: 12/11/19 |
12/11/2019
| Implemented |
| 6500.125(c)(3) | Family member #2 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection. The individual's physicians have not provided a statement that the family members are free of communicable diseases or specific precautions to be taken if the person has a communicable disease. | The physical examination shall include: (3) A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. | Why is the regulation important? This regulation is important in order to prevent the spread of a communicable disease within the home that is occupied by a life sharing resident.
What happened? Family member #1 and her two children, ages 4 years and 8 months old, have moved back into the residence since the last year's inspection. The individual's physicians have not provided a statement that the family members are free of communicable diseases or specific precautions to be taken if the person has a communicable disease.
Why did it happen? This was an oversight of the Life Sharing Specialist to secure a new physical on family member #1 and her two children. The adult daughter and children unexpectedly moved back into the family home with her two children and physicals were not on file.
What do we do right now? Updated physicals that include a statement from the physician that a family member is free of communicable disease was completed on all three family members in question. (Attachment#1,2 &3)
How do we prevent this from happening again? Prior to someone moving into the licensed Life Sharing home, a physical will be completed on that person. Life Sharing Provider will inform LS Specialist of any such changes. LS Provider was re-trained on this regulation on 10/29/19. (Attachment#4) Corrected: 12/11/19 |
12/11/2019
| Implemented |
| Article X.1007 | Compass Community Connections is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 moved back into the home, along with her two children ages 4 years and 8 months old, during the last licensing year. The criminal history check for Staff #1, since she is over 18 years of age, was never requested. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Why is the regulation important? This regulation is important to ensure that all individuals currently living in the home or moving into the home meet all requirements of Article X.1007.
What happened? Staff #1 moved back into the home, along with her two children ages 4 years and 8 months old, during the last licensing year. The criminal history check for Staff #1, since she is over 18 years of age, was never requested.
Why did it happen? This was an oversight of the Life Sharing Specialist to secure a new criminal background clearance. The adult daughter and children unexpectedly moved back into the family home without prior notice.
What do we do right now? A criminal background check was immediately obtained on staff #1. This was completed on 10/29/19. (Attachment #11)
How do we prevent this from happening again? In the future, Life Sharing provider will inform the Life Sharing Specialist of any changes in residents in and out of the home. Life Sharing Provider was trained on this reg. on 10/29/19 (attachment#4) |
10/29/2019
| Implemented |