Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(f) | The door at the front of the home was used as the exit route in the fire drills held from 11/26/2019 to 1/14/2021. The home has two exit routes. | Alternate exit routes shall be used during fire drills. | A fire drill was conducted on 2/16/2021 with staff on duty and individuals using the back door entrance. The fire drill was documented and received by the program specialist to review and sign. Going forward, all monthly fire drills will be completed by staff, reviewed and signed by the program specialist, and then reviewed and signed by the program director to ensure that both exits are being used during the completion of the fire drill. All staff were trained on regulation 6400.112(f). Supporting documentation attached. |
02/16/2021
| Implemented |
6400.52(c)(2) | Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not encompass 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. | 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. | Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(2). Supporting documentation attached. |
02/15/2021
| Implemented |
6400.52(c)(3) | Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(3). Supporting documentation attached. |
02/15/2021
| Implemented |
6400.52(c)(4) | Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include recognizing and reporting Incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(4). Supporting documentation attached. |
02/15/2021
| Implemented |
6400.52(c)(6) | Program Specialist #1's annual training hours for training year, January 1, 2020 to December 31, 2020, did not include the implementation of the individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Program specialist and staff received training on 2/15/2021, 2/16/2021, and 2/19/2021. The program director will be responsible for training the program specialist. The program director will review the training records of all staff and program specialist to ensure that the annual timeline is met and that the correct training is received on an annual basis. Staff as well as program specialist also received training on regulation 6400.5(c)(6). Supporting documentation attached. |
02/15/2021
| Implemented |