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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On the floor of the bathroom on the second floor were soiled towels and clothing, empty toilet paper rolls, wrapper and strips from sanitary napkins, pieces of paper and liquid soap and shampoo bottles. In the same bathroom, there was a black substance along the caulking where the bathtub meets the floor and on the floor between the vanity and the bathtub. A cardboard box containing a full garbage bag was located on the interior stairs near the back door of the home. There were stains and drops of hardened liquids on the lid of the trash receptacle in the kitchen. | Clean and sanitary conditions shall be maintained in the home. | The staff person received discipline for not completing his designat4d responsibilities. A chore chart was also developed and put in place. The staff were all trained o0nthe choir chart.[A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on ¿Cleaning Checklist¿ by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.66 | The outside light on the front porch of the house was completely covered by a bird's nest. There is no other source of light in this area. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The birds nest was removed and the staff are to complete a monthly checklist to ensure that the light is in working condition.[CEO or designee will immediately check all homes to ensure all areas of all homes are have adequate light to ensure safety and avoid accidents. A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.67(a) | In the bathroom on the second floor, the wood on the side of the vanity facing the bathtub is delaminating from the vanity. At the bottom of the steps in the basement is a puddle 2 feet by 2 feet and approximately ¼ inch deep of a clear liquid. In the powder room on the main floor, the cabinet above the toilet has broken and missing pieces of wicker in both doors | Floors, walls, ceilings and other surfaces shall be in good repair. | The vanity was repaired and the staff were trained on completing work orders. The Team Leaders conduct unannounced visits to ensure there are no additional problems. Forms will be sent.[A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.67(b) | There is a four and a half inch hole in the carpet on the front of the fifth step leading to the second floor, which poses a potential tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The carpeting was ripped out and the staff were trained on completing work orders.[A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.72(a) | There was a hole measuring 2 inches by 3 inches in the privacy glass of the window in the bathroom on the second floor; in addition, pieces of broken glass were between the two window panes and shards of glass were on the window sill. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The window was repaired and the staff were trained on completing work orders.[A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.105 | A fabric lawn umbrella was partially underneath the furnace. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Staff will complete a checklist to ensure the furnace is free of any type of items that could cause a potential harm. Checklist attached.[A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/15. (AS 12/1/15)] |
11/16/2015
| Implemented |
| 6400.110(a) | The smoke detector in the basement of the home was chirping, indicating a low battery. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The smoke alarm in the basement was an extra alarm. The home is equipped with inter connected detectors. [CEO or designee will check all smoke detectors at all homes to ensure they are in working order. A blank "physical site review" which includes "fire safety, Cleanliness, general safety, bedrooms, bathrooms, first aid kit and notes" headings was submitted to the department. A hand written note "complete monthly" is at the top. An additional, blank "Sunday through Thursday midnight chore list" was submitted with instructions for 2 staff to initial upon completion of the chore. A training session documentation with a one hour training, titled "Cleaning checklist" was completed in July, 2015 with 6 signatures of attendees was submitted to the Department. The CEO or designee will review the above mentioned "chore lists" at least monthly for completion and compare to the actual duties that are to be completed. CEO or designee will do unannounced visits to this home at least weekly for the next 3 months to ensure the home is clean, in good repair and safe including fire safety, tripping hazards, lightening. CEO or designee will do unannounced visits at all community home at least monthly for the next 6 months to ensure the homes are clean, in good repair and safe. If any areas of concern (fire safety, tripping hazards, unlit areas, unclean areas etc) are found at any of the homes, CEO or designee will increase unannounced visits to at least weekly at that home. All staff at all community homes will be trained for at least one hour on "Cleaning Checklist" by 2/15/16. Documentation of unannounced visits, chore lists, chore list reviews and trainings will be kept. A 25% sample of the completed documentation will be submitted to the department via email to ascharpf@pa.gov by 2/28/16. (AS 12/1/15)] |
11/16/2015
| Implemented |
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